Provider Demographics
NPI:1932229390
Name:ANJUM, EHTESHAMUL HAQUE (MD)
Entity Type:Individual
Prefix:
First Name:EHTESHAMUL
Middle Name:HAQUE
Last Name:ANJUM
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 1:903 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2970
Mailing Address - Country:US
Mailing Address - Phone:608-741-3814
Mailing Address - Fax:608-741-3816
Practice Address - Street 1:903 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2970
Practice Address - Country:US
Practice Address - Phone:608-741-3814
Practice Address - Fax:608-741-3816
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2013-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97863207RN0300X
WI60106-20207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278131000Medicaid
FL278131000Medicaid
FLAF312ZMedicare PIN