Provider Demographics
NPI:1376757617
Name:M A MIRZA, LLC
Entity Type:Organization
Organization Name:M A MIRZA, LLC
Other - Org Name:WHITE OAK PSYCHIATRIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:AZHER
Authorized Official - Last Name:MIRZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-228-5335
Mailing Address - Street 1:4045 NE LAKEWOOD WAY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-1799
Mailing Address - Country:US
Mailing Address - Phone:816-886-2184
Mailing Address - Fax:816-886-2397
Practice Address - Street 1:4045 NE LAKEWOOD WAY
Practice Address - Street 2:SUITE 130
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-1799
Practice Address - Country:US
Practice Address - Phone:816-886-2184
Practice Address - Fax:816-886-2397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2014-03-21
Deactivation Date:2008-08-14
Deactivation Code:
Reactivation Date:2013-05-14
Provider Licenses
StateLicense IDTaxonomies
MORICIO103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty