Provider Demographics
NPI:1093911935
Name:OCALA INFECTIOUS DISEASE AND WOUND CENTER, INC
Entity Type:Organization
Organization Name:OCALA INFECTIOUS DISEASE AND WOUND CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARIS
Authorized Official - Middle Name:INAM
Authorized Official - Last Name:MIRZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-401-7552
Mailing Address - Street 1:PO BOX 5580
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34478-5580
Mailing Address - Country:US
Mailing Address - Phone:352-401-7552
Mailing Address - Fax:352-622-7945
Practice Address - Street 1:321 SE 29TH PL
Practice Address - Street 2:SUITE 101
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-0489
Practice Address - Country:US
Practice Address - Phone:352-401-7552
Practice Address - Fax:352-622-7945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88195207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267672900Medicaid
K8951OtherMEDICARE PTAN
FL267672900Medicaid