Provider Demographics
NPI:1942788302
Name:HAQUE, SYED MANSURUL (MD)
Entity Type:Individual
Prefix:
First Name:SYED
Middle Name:MANSURUL
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 1:2231 E 95TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4804
Mailing Address - Country:US
Mailing Address - Phone:773-768-7700
Mailing Address - Fax:773-273-8915
Practice Address - Street 1:2231 E 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4804
Practice Address - Country:US
Practice Address - Phone:773-768-7700
Practice Address - Fax:773-273-8915
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-29
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8277207R00000X
IL036160915207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine