Provider Demographics
NPI:1164465639
Name:HAQUE, MOSTA GAUSEL (MD)
Entity Type:Individual
Prefix:
First Name:MOSTA
Middle Name:GAUSEL
Last Name:HAQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 GOODE WAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2266
Mailing Address - Country:US
Mailing Address - Phone:757-397-0700
Mailing Address - Fax:757-397-8751
Practice Address - Street 1:301 GOODE WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-2266
Practice Address - Country:US
Practice Address - Phone:757-397-0700
Practice Address - Fax:757-397-8751
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-048420207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010236801Medicaid
VA187692OtherANTHEM BC /BS
VAP00273296OtherRAILROAD MEDICARE
VA187692OtherANTHEM BC /BS
VA00W915M01Medicare ID - Type Unspecified