Provider Demographics
NPI:1164859336
Name:MIRZAEI, ALLEN (DPM)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:MIRZAEI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 N SHIPLEY ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-2339
Mailing Address - Country:US
Mailing Address - Phone:302-629-3000
Mailing Address - Fax:302-629-3080
Practice Address - Street 1:543 N SHIPLEY ST
Practice Address - Street 2:SUITE C
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-2339
Practice Address - Country:US
Practice Address - Phone:302-629-3000
Practice Address - Fax:302-629-3080
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006482213ES0103X
DEE1-0000235213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE529602YD92Medicare PIN