Provider Demographics
NPI:1376573204
Name:MIRZA, IMRAN A (MD)
Entity Type:Individual
Prefix:
First Name:IMRAN
Middle Name:A
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 69
Mailing Address - Street 2:
Mailing Address - City:MICKLETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08056-0069
Mailing Address - Country:US
Mailing Address - Phone:856-381-9598
Mailing Address - Fax:
Practice Address - Street 1:1132 COOPER ST
Practice Address - Street 2:
Practice Address - City:DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-3014
Practice Address - Country:US
Practice Address - Phone:856-848-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08024700207R00000X, 261QU0200X
PAMD431989207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019810230002Medicaid
PA1019810230001Medicaid
PA1980195OtherBS HIGHMARK
PA1019810230002Medicaid
PA115390S52Medicare PIN