Provider Demographics
NPI:1659480747
Name:MIRZA-GRUBER, MANIZEH (MD)
Entity Type:Individual
Prefix:
First Name:MANIZEH
Middle Name:
Last Name:MIRZA-GRUBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANIZEH
Other - Middle Name:
Other - Last Name:MIRZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 PIERCE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002
Mailing Address - Country:US
Mailing Address - Phone:888-792-7122
Mailing Address - Fax:888-317-7014
Practice Address - Street 1:410 PIERCE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-8646
Practice Address - Country:US
Practice Address - Phone:888-792-7122
Practice Address - Fax:888-317-7014
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ43572084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX188429801Medicaid
TX188429801Medicaid
TXP00458742Medicare PIN