Provider Demographics
NPI:1558364372
Name:HAQUE, AHSANUL (MD)
Entity Type:Individual
Prefix:DR
First Name:AHSANUL
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:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2968
Mailing Address - Country:US
Mailing Address - Phone:574-296-3307
Mailing Address - Fax:574-296-3328
Practice Address - Street 1:303 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2066
Practice Address - Country:US
Practice Address - Phone:574-296-3307
Practice Address - Fax:574-296-3328
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049498A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200481130Medicaid
IN200481130Medicaid
IN227950UUUUMedicare PIN