Healthcare Provider Details

I. General information

NPI: 1497847149
Provider Name (Legal Business Name): EHTSHAM U HAQ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 02/01/2024
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4371 NARROW LANE RD STE 205
MONTGOMERY AL
36116-2975
US

IV. Provider business mailing address

301 BROWN SPRINGS RD
MONTGOMERY AL
36117-7005
US

V. Phone/Fax

Practice location:
  • Phone: 334-747-7780
  • Fax: 334-747-7790
Mailing address:
  • Phone: 334-747-4159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number24156
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: