Basic Information
| Provider Information | |||||||||
| NPI: | 1669647889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDDIQUI | ||||||||
| FirstName: | WAJID | ||||||||
| MiddleName: | ALI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967303 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 TAYLOR ST | ||||||||
| Address2: | SUITE 6-F | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032963273 | ||||||||
| FaxNumber: | 8032967061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MT186425 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 34048 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 340483 | 05 | SC | MEDICAID |