Provider Demographics
NPI:1497701072
Name:MIRZA, ATIQUE AZAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ATIQUE
Middle Name:AZAM
Last Name:MIRZA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:19 WOODLAND ST
Mailing Address - Street 2:SUITE# 47
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2372
Mailing Address - Country:US
Mailing Address - Phone:860-525-4005
Mailing Address - Fax:860-525-4839
Practice Address - Street 1:19 WOODLAND ST
Practice Address - Street 2:SUITE# 35
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2372
Practice Address - Country:US
Practice Address - Phone:860-525-1234
Practice Address - Fax:860-278-8782
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2015-07-07
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Provider Licenses
StateLicense IDTaxonomies
CT041416207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTG34084Medicare UPIN