Provider Demographics
NPI:1508909540
Name:MIRZAI, MICHAEL AV (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:AV
Last Name:MIRZAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 E INTERSTATE AVE STE B
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1566
Practice Address - Country:US
Practice Address - Phone:701-323-6543
Practice Address - Fax:701-323-5492
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND125022084P0800X, 2084P0804X
TXK-67772084P0800X, 2084P0804X
HI126162084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1452924Medicaid
ND1452924Medicaid