Provider Demographics
NPI:1376637256
Name:SHIRWAN A MIRZA, MD
Entity Type:Organization
Organization Name:SHIRWAN A MIRZA, MD
Other - Org Name:ENDOCRINOLOGY, DIABETES, AND METABOLISM, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRWAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MIRZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-282-0071
Mailing Address - Street 1:399 GRANT AVENUE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-8202
Mailing Address - Country:US
Mailing Address - Phone:315-282-0071
Mailing Address - Fax:315-282-0077
Practice Address - Street 1:399 GRANT AVENUE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-8202
Practice Address - Country:US
Practice Address - Phone:315-282-0071
Practice Address - Fax:315-282-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221927207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02959424Medicaid