Provider Demographics
NPI:1871783407
Name:HAQUE, NIAZ M (MD)
Entity type:Individual
Prefix:
First Name:NIAZ
Middle Name:M
Last Name:HAQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-387-5511
Mailing Address - Fax:
Practice Address - Street 1:3501 CRANBERRY BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-5213
Practice Address - Country:US
Practice Address - Phone:715-393-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20720208M00000X
WI57472207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09807236Medicaid
LA1077402Medicaid
MS302I116546Medicare PIN