Provider Demographics
NPI:1497711626
Name:MIRZA, ALI (MD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
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 1:200 W ARBOR DR
Mailing Address - Street 2:MC 0840 UCSD MEDICAL CENTER HILLCREST
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-9000
Mailing Address - Country:US
Mailing Address - Phone:858-657-8440
Mailing Address - Fax:858-657-8069
Practice Address - Street 1:9350 CAMPUS POINT DR
Practice Address - Street 2:SUITE 2B MAIL CODE 0975
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1300
Practice Address - Country:US
Practice Address - Phone:858-657-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086775207R00000X
CAC54460207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1497711626Medicaid
OH2613541Medicaid
CA1497711626Medicaid
OHI09751Medicare UPIN