Provider Demographics
NPI:1700884111
Name:HAQUE, MAX MAHFUZUL (MD)
Entity Type:Individual
Prefix:MR
First Name:MAX
Middle Name:MAHFUZUL
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 228
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-0228
Mailing Address - Country:US
Mailing Address - Phone:740-380-4181
Mailing Address - Fax:740-385-0865
Practice Address - Street 1:1389 W HUNTER ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-1013
Practice Address - Country:US
Practice Address - Phone:740-385-2197
Practice Address - Fax:740-385-9197
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-0607-H2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35070607HOtherSTATE LICENSE
OH2050999Medicaid
OHG34796Medicare UPIN
OH2050999Medicaid
OHHA4012014Medicare ID - Type Unspecified