Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RG0100X | Gastroenterologist | 2013004553 | MO |
NPI | 1023260874 |
---|---|
Provider Name | Ghulam Jeelani Siddiqui |
First Address | Saint Louis, MO 63150-5164 |
Second Address | Springfield, MO 65804-2239 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2008 |
Last Update Date | 06/02/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1023260874 | (05) | MO |