Provider Demographics
NPI:1295854362
Name:MIRZA, MADIHA A (MD)
Entity Type:Individual
Prefix:
First Name:MADIHA
Middle Name:A
Last Name:MIRZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 LIMESTONE DR
Mailing Address - Street 2:SUITE 10
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8602
Mailing Address - Country:US
Mailing Address - Phone:716-633-0057
Mailing Address - Fax:716-633-0378
Practice Address - Street 1:18 LIMESTONE DR
Practice Address - Street 2:SUITE 10
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8602
Practice Address - Country:US
Practice Address - Phone:716-633-0057
Practice Address - Fax:716-633-0378
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181870-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01557597Medicaid
RA8847Medicare ID - Type Unspecified