Provider Demographics
NPI:1508252321
Name:JUSTIN MIRZA D.O. PC
Entity Type:Organization
Organization Name:JUSTIN MIRZA D.O. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:BRUNO
Authorized Official - Last Name:MIRZA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-361-5302
Mailing Address - Street 1:290 E MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2916
Mailing Address - Country:US
Mailing Address - Phone:631-361-5302
Mailing Address - Fax:631-361-8607
Practice Address - Street 1:290 E MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2916
Practice Address - Country:US
Practice Address - Phone:631-361-5302
Practice Address - Fax:631-361-8607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258198207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty