Provider Demographics
NPI:1225467467
Name:MIRZA, SHAHZAIB (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAHZAIB
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:PO BOX 919771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9771
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:
Practice Address - Street 1:4300 KINGS HWY STE 500
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-2953
Practice Address - Country:US
Practice Address - Phone:393-442-3252
Practice Address - Fax:941-764-6176
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME128220208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017589500Medicaid