Provider Demographics
NPI:1497762850
Name:MIRZA, SHIRWAN (MD)
Entity Type:Individual
Prefix:
First Name:SHIRWAN
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 1:399 GRANT AVENUE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-8202
Mailing Address - Country:US
Mailing Address - Phone:315-253-2669
Mailing Address - Fax:315-282-0077
Practice Address - Street 1:399 GRANT AVENUE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-8202
Practice Address - Country:US
Practice Address - Phone:315-253-2669
Practice Address - Fax:315-282-0077
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221927207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01800797Medicaid
NYAA1005Medicare PIN
NYCC9009Medicare PIN
NY01800797Medicaid
NYG80355Medicare UPIN