Provider Demographics
NPI:1558500587
Name:MIRZA, IMRAN HUMAYUN (MD)
Entity Type:Individual
Prefix:DR
First Name:IMRAN
Middle Name:HUMAYUN
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 1:4521 PGA BLVD
Mailing Address - Street 2:PMB 267
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418
Mailing Address - Country:US
Mailing Address - Phone:716-601-9178
Mailing Address - Fax:
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2700
Practice Address - Country:US
Practice Address - Phone:386-425-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME113910207Q00000X, 208M00000X
GA79899207Q00000X, 207Q00000X
TXP8055208M00000X
IN01071271A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist