Provider Demographics
NPI:1437159597
Name:MIRZA, NADEEM M (MD)
Entity Type:Individual
Prefix:
First Name:NADEEM
Middle Name:M
Last Name:MIRZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:404 HAZEN ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1040
Mailing Address - Country:US
Mailing Address - Phone:269-657-1595
Mailing Address - Fax:269-657-1534
Practice Address - Street 1:404 HAZEN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1040
Practice Address - Country:US
Practice Address - Phone:269-657-1595
Practice Address - Fax:269-657-1534
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010862272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H060020OtherBCBSM
MI1437159597Medicaid
MI104995020Medicaid
MIBM6414825OtherDEA
MIBM6414825OtherDEA
MI0H06012021Medicare PIN
MI700H060020Medicare PIN