Provider Demographics
NPI:1508895020
Name:MIRZA, NATASHA (MD)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:MIRZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:5 SILVERSTEIN
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-2979
Mailing Address - Fax:215-662-4182
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:5 SILVERSTEIN
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-2979
Practice Address - Fax:215-662-4182
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050143L207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015553970002Medicaid
PA0015553970002Medicaid
PA812347Medicare PIN