Provider Demographics
NPI:1699987800
Name:HAQUE, MAHMUDUL (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:MAHMUDUL
Middle Name:
Last Name:HAQUE
Suffix:
Gender:M
Credentials:MD, PHD
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 249
Mailing Address - Street 2:SAME
Mailing Address - City:HIGHLAND CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33846-0249
Mailing Address - Country:US
Mailing Address - Phone:863-802-1111
Mailing Address - Fax:863-802-6711
Practice Address - Street 1:805 EAST GARDEN STREET
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4616
Practice Address - Country:US
Practice Address - Phone:863-802-1111
Practice Address - Fax:863-802-6711
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93947207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274846100Medicaid
FLU5863AMedicare PIN
FLI40223Medicare UPIN