Provider Demographics
NPI:1306036934
Name:HAQUE, SHIREEN (MD)
Entity Type:Individual
Prefix:
First Name:SHIREEN
Middle Name:
Last Name:HAQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 RIDENOUR BLVD NW STE 300
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4402
Mailing Address - Country:US
Mailing Address - Phone:707-702-1806
Mailing Address - Fax:707-693-0801
Practice Address - Street 1:1266 HIGHWAY 515 S
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-4872
Practice Address - Country:US
Practice Address - Phone:706-301-5434
Practice Address - Fax:706-301-5438
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252856207L00000X
NC201100645207L00000X
GA73579207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5918210Medicaid
LA1000744Medicaid
NCNC1944AMedicaid
SCNC1473Medicaid
VA1306036934Medicaid