Provider Demographics
NPI:1386646560
Name:MIRZA, MOHAMMAD H (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:H
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 1:7603 ROUTE 54
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-7930
Mailing Address - Country:US
Mailing Address - Phone:607-776-4176
Mailing Address - Fax:607-776-8032
Practice Address - Street 1:7603 ROUTE 54
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-7930
Practice Address - Country:US
Practice Address - Phone:607-776-4176
Practice Address - Fax:607-776-8032
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01236337Medicaid
NYAA0506Medicare PIN
NY01236337Medicaid