Basic Information
Provider Information | |||||||||
NPI: | 1720154008 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAQ | ||||||||
FirstName: | IHTSHAM | ||||||||
MiddleName: | UL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 344 | ||||||||
Address2: |   | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271020344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367162011 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1120 NW 14TH ST STE 1363 | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331362107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3052435823 | ||||||||
FaxNumber: | 3052434713 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2006 | ||||||||
LastUpdateDate: | 10/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 2009-01176 | NC | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | ME146527 | FL | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 5912174 | 05 | NC |   | MEDICAID |