Provider Demographics
NPI:1508974502
Name:MIRZA, MANSOOR HUSSAIN (MD)
Entity Type:Individual
Prefix:
First Name:MANSOOR
Middle Name:HUSSAIN
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 1:3600 ROUTE 66 FL 3
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-2645
Mailing Address - Country:US
Mailing Address - Phone:732-807-0877
Mailing Address - Fax:201-751-1680
Practice Address - Street 1:2414 KOHLER MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3129
Practice Address - Country:US
Practice Address - Phone:920-457-4461
Practice Address - Fax:920-459-1483
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48060207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00138179OtherNETWORK HEALTH PLAN
WVP00252461OtherRAILROAD MEDICARE
WI132679OtherCIGNA
WI390806395002OtherTRICARE
WI34652100Medicaid
WI390806395002OtherTRICARE
WI132679OtherCIGNA
WI34652100Medicaid
WI34652100Medicaid