Provider Demographics
NPI:1528038478
Name:MIRZA, MEDO (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MEDO
Middle Name:
Last Name:MIRZA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 S DOBSON RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4768
Mailing Address - Country:US
Mailing Address - Phone:480-464-9400
Mailing Address - Fax:480-464-9401
Practice Address - Street 1:1432 S DOBSON RD
Practice Address - Street 2:SUITE 301
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4768
Practice Address - Country:US
Practice Address - Phone:480-464-9400
Practice Address - Fax:480-464-9401
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ174262086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ27694001Medicaid
AZ27694001OtherAHCCCS
E89536Medicare UPIN