Provider Demographics
NPI:1528003050
Name:MIRZA, MASHHUD M (MD)
Entity Type:Individual
Prefix:
First Name:MASHHUD
Middle Name:M
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:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-0055
Mailing Address - Country:US
Mailing Address - Phone:870-733-1177
Mailing Address - Fax:870-702-6128
Practice Address - Street 1:1120 STATE HIGHWAY 77
Practice Address - Street 2:STE 1
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-9027
Practice Address - Country:US
Practice Address - Phone:870-733-1177
Practice Address - Fax:870-702-6128
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1005207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3154566OtherBLUE CROSS
AR5K483OtherBLUE CROSS
AR136518001Medicaid
110217316OtherRAILROAD MEDICARE
AR5K483OtherBLUE CROSS
TN3154566OtherBLUE CROSS
G48672Medicare UPIN
MS110001483Medicare ID - Type Unspecified