Provider Demographics
NPI:1821269887
Name:HAQUE, EHTESHAMUL
Entity Type:Individual
Prefix:
First Name:EHTESHAMUL
Middle Name:
Last Name:HAQUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 ARMOUR RD
Mailing Address - Street 2:SUITE A-4
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5296
Mailing Address - Country:US
Mailing Address - Phone:706-649-7676
Mailing Address - Fax:706-649-5497
Practice Address - Street 1:4820 ARMOUR RD
Practice Address - Street 2:SUITE A-4
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5296
Practice Address - Country:US
Practice Address - Phone:706-649-7676
Practice Address - Fax:706-649-5497
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5896400001Medicare NSC