Provider Demographics
NPI:1619904240
Name:MIRZA, MOHAMMED ATHER (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:ATHER
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 1:290 E MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2916
Mailing Address - Country:US
Mailing Address - Phone:631-361-5302
Mailing Address - Fax:631-361-8607
Practice Address - Street 1:290 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2916
Practice Address - Country:US
Practice Address - Phone:631-361-5302
Practice Address - Fax:631-361-8607
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117684207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDR7510OtherOXFORD
NYDR7510OtherOXFORD
NYB78119Medicare UPIN
NY580121Medicare ID - Type Unspecified