Provider Demographics
NPI:1053489609
Name:MIRZA, FAYYAZ H (MD)
Entity Type:Individual
Prefix:DR
First Name:FAYYAZ
Middle Name:H
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 1:808 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4209
Mailing Address - Country:US
Mailing Address - Phone:940-766-0217
Mailing Address - Fax:940-766-0730
Practice Address - Street 1:808 BROOK AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4209
Practice Address - Country:US
Practice Address - Phone:940-766-0217
Practice Address - Fax:940-766-0730
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG11182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81R702OtherBLUE CROSS BLUE SHIELD
TXA011OtherHUMANA MILITARY HEALTHCAR
TX123812OtherSUPERIOR HEALTH PLAN
TXA011OtherHUMANA MILITARY HEALTHCAR
TXB95664Medicare UPIN