Provider Demographics
NPI:1538130810
Name:HAQUE, EHTESHAMUL (MD)
Entity Type:Individual
Prefix:DR
First Name:EHTESHAMUL
Middle Name:
Last Name:HAQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1443 NORTH VEAUX LOOP
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23509-1259
Mailing Address - Country:US
Mailing Address - Phone:757-627-3898
Mailing Address - Fax:757-627-0054
Practice Address - Street 1:1443 N VEAUX LOOP
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23509-1259
Practice Address - Country:US
Practice Address - Phone:757-627-3898
Practice Address - Fax:757-627-0054
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2008-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231617207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
461932OtherANTHEM BC
58013OtherSENTARA OPTIMA
VA5862345Medicaid
G16752Medicare UPIN