Provider Demographics
NPI:1386684280
Name:MIRSON, SOFIYA (MD)
Entity Type:Individual
Prefix:
First Name:SOFIYA
Middle Name:
Last Name:MIRSON
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 1:811 SUNSET RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-3645
Mailing Address - Country:US
Mailing Address - Phone:609-387-9242
Mailing Address - Fax:609-387-9408
Practice Address - Street 1:950 S CHESTER AVE STE A
Practice Address - Street 2:SUITE 10
Practice Address - City:DELRAN
Practice Address - State:NJ
Practice Address - Zip Code:08075-1272
Practice Address - Country:US
Practice Address - Phone:856-764-2500
Practice Address - Fax:856-764-8335
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426536207R00000X
NJ25MA07944800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0315931Medicaid
PA101290599Medicaid
PA101290599Medicaid