Provider Demographics
NPI:1083489843
Name:ADNAN, MIRZA
Entity Type:Individual
Prefix:
First Name:MIRZA
Middle Name:
Last Name:ADNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 GENESEE AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-3206
Mailing Address - Country:US
Mailing Address - Phone:347-662-9009
Mailing Address - Fax:
Practice Address - Street 1:600 E CRESCENT AVE STE 305
Practice Address - Street 2:
Practice Address - City:UPPER SADDLE RIVER
Practice Address - State:NJ
Practice Address - Zip Code:07458-1846
Practice Address - Country:US
Practice Address - Phone:845-738-8770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP125651207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty