Provider Demographics
NPI:1215674858
Name:ISHTIAQ, M FATIN (MD)
Entity type:Individual
Prefix:
First Name:M FATIN
Middle Name:
Last Name:ISHTIAQ
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 1:506 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215
Mailing Address - Country:US
Mailing Address - Phone:718-780-5130
Mailing Address - Fax:
Practice Address - Street 1:100 MCGREGOR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3770
Practice Address - Country:US
Practice Address - Phone:332-260-8749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2025-07-07
Deactivation Date:2023-01-13
Deactivation Code:
Reactivation Date:2024-01-23
Provider Licenses
StateLicense IDTaxonomies
390200000X
NH34561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program