Provider Demographics
NPI:1255660775
Name:ABDUL B MIR MD PA
Entity Type:Organization
Organization Name:ABDUL B MIR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:MIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-682-5174
Mailing Address - Street 1:131 E REDSTONE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5326
Mailing Address - Country:US
Mailing Address - Phone:850-682-5174
Mailing Address - Fax:850-689-3653
Practice Address - Street 1:131 E REDSTONE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5326
Practice Address - Country:US
Practice Address - Phone:850-682-5174
Practice Address - Fax:850-689-3653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0032883207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty