Provider Demographics
NPI:1902899958
Name:HAQ, IFTIKHAR FAZAL (DO)
Entity Type:Individual
Prefix:DR
First Name:IFTIKHAR
Middle Name:FAZAL
Last Name:HAQ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 VINTAGE LN
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-8555
Mailing Address - Country:US
Mailing Address - Phone:386-325-5801
Mailing Address - Fax:386-325-4777
Practice Address - Street 1:100 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656-6802
Practice Address - Country:US
Practice Address - Phone:352-473-6595
Practice Address - Fax:352-473-6597
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80804OtherBLUE CROSS BLUE SHIELD
FLPENDINGMedicaid
FLF61434Medicare UPIN
FLK8476Medicare ID - Type Unspecified