Provider Demographics
NPI:1033149232
Name:MIRZA, ABBAS (MD)
Entity Type:Individual
Prefix:
First Name:ABBAS
Middle Name:
Last Name:MIRZA
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 1:9377 FIR HILL DR N
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002-9468
Mailing Address - Country:US
Mailing Address - Phone:901-266-3795
Mailing Address - Fax:
Practice Address - Street 1:1995 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3635
Practice Address - Country:US
Practice Address - Phone:901-476-1727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38898207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4155136OtherBLUE CROSS
TN1511099Medicaid
TN3897246Medicare ID - Type Unspecified
TN1511099Medicaid