Provider Demographics
NPI:1689604100
Name:HAQUE, MOHAMMED MOMINUL (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:MOMINUL
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 1449
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0449
Mailing Address - Country:US
Mailing Address - Phone:314-713-3665
Mailing Address - Fax:
Practice Address - Street 1:4455 DUNCAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1111
Practice Address - Country:US
Practice Address - Phone:314-658-3800
Practice Address - Fax:636-333-4510
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2023-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160353207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205437833Medicaid
MO205437833Medicaid
MOH31235Medicare UPIN