Provider Demographics
NPI:1407734544
Name:EHTISHAM-UL HAG, FNU
Entity type:Individual
Prefix:
First Name:FNU
Middle Name:
Last Name:EHTISHAM-UL HAG
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 1:6420 CLAYTON RD ST. MARY'S HOSPITAL-ST. LOUIS
Mailing Address - Street 2:DEPT OF INTERNAL MEDICINE 2ND FLOOR
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117
Mailing Address - Country:US
Mailing Address - Phone:314-768-8778
Mailing Address - Fax:314-768-7101
Practice Address - Street 1:6420 CLAYTON RD ST. MARY'S HOSPITAL-ST. LOUIS
Practice Address - Street 2:DEPT OF INTERNAL MEDICINE 2ND FLOOR
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117
Practice Address - Country:US
Practice Address - Phone:314-768-8778
Practice Address - Fax:314-768-7101
Is Sole Proprietor?:No
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025024125390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program