1063404911 NPI number — MAHFUZUL HAQUE MD

Table of content: MAHFUZUL HAQUE MD (NPI 1063404911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063404911 NPI number — MAHFUZUL HAQUE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAQUE
Provider First Name:
MAHFUZUL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063404911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751069
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28275-1069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-744-3253
Provider Business Mailing Address Fax Number:
252-744-3194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 W 5TH ST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27834-2888
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-744-2207
Provider Business Practice Location Address Fax Number:
252-744-1115
Provider Enumeration Date:
08/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  200300110 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00013007 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1330E . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 891330E , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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