Provider Demographics
NPI:1609886647
Name:RAHEEM, MIRZA (MD)
Entity Type:Individual
Prefix:
First Name:MIRZA
Middle Name:
Last Name:RAHEEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 WABASH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-4364
Mailing Address - Country:US
Mailing Address - Phone:219-878-1300
Mailing Address - Fax:219-878-9764
Practice Address - Street 1:9850 GENESEE AVE STE 320
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1208
Practice Address - Country:US
Practice Address - Phone:858-554-1212
Practice Address - Fax:858-795-1195
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140215207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100095230CMedicaid
C25131Medicare UPIN
IN1277001Medicare PIN