Basic Information
| Provider Information | |||||||||
| NPI: | 1154640324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDDIQUE | ||||||||
| FirstName: | KHURRUM | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SANTA ROSA | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137981750 | ||||||||
| FaxNumber: | 7117984693 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 N SANTA ROSA | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137981750 | ||||||||
| FaxNumber: | 7117984693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2010 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0210X | P6084 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 321120302 | 05 | TX | MEDICAID |