Provider Demographics
NPI:1124102405
Name:HAQUE, ANGIE RENEE (DO)
Entity type:Individual
Prefix:DR
First Name:ANGIE
Middle Name:RENEE
Last Name:HAQUE
Suffix:
Gender:
Credentials:DO
Other - Prefix:DR
Other - First Name:ANGIE
Other - Middle Name:RENEE
Other - Last Name:SMITH-HAQUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:6600 VAN AALST BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2102
Mailing Address - Country:US
Mailing Address - Phone:762-408-2273
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:762-408-2273
Practice Address - Fax:762-408-8300
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59765207Q00000X
GA059765207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA068846053DMedicaid
GA202I089077OtherMEDICARE PTAN