Provider Demographics
NPI:1588612592
Name:MIRZA, ASIF
Entity Type:Individual
Prefix:MR
First Name:ASIF
Middle Name:
Last Name:MIRZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 ROCKDALE LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5332
Mailing Address - Country:US
Mailing Address - Phone:407-333-1928
Mailing Address - Fax:407-936-0977
Practice Address - Street 1:2500 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3501
Practice Address - Country:US
Practice Address - Phone:407-936-0976
Practice Address - Fax:407-936-0977
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78737207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260955000Medicaid
FL49612ZMedicare PIN
FLG38822Medicare UPIN