Provider Demographics
NPI:1205849270
Name:MIRZA, TASNEEM (MD)
Entity Type:Individual
Prefix:DR
First Name:TASNEEM
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 1:5333 N DIXIE HWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-3414
Mailing Address - Country:US
Mailing Address - Phone:954-771-4747
Mailing Address - Fax:954-491-6841
Practice Address - Street 1:5333 N DIXIE HWY
Practice Address - Street 2:SUITE 106
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-3414
Practice Address - Country:US
Practice Address - Phone:954-771-4747
Practice Address - Fax:954-491-6841
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44296208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE30527Medicare UPIN