Provider Demographics
NPI:1013038512
Name:MOHAMMAD A MIRZA MD SC
Entity Type:Organization
Organization Name:MOHAMMAD A MIRZA MD SC
Other - Org Name:MA MIRZA MD SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:MIRZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-735-4600
Mailing Address - Street 1:6723 S PULASKI ROAD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4118
Mailing Address - Country:US
Mailing Address - Phone:773-735-4600
Mailing Address - Fax:773-735-3112
Practice Address - Street 1:6723 S PULASKI ROAD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4118
Practice Address - Country:US
Practice Address - Phone:773-735-4600
Practice Address - Fax:773-735-3112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
455070Medicare ID - Type UnspecifiedUNDER MOHAMMAD A MIRZA MD
D13425Medicare UPIN