Provider Demographics
NPI:1679599922
Name:MIRZA, IMRAN (MD)
Entity Type:Individual
Prefix:
First Name:IMRAN
Middle Name:
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 1:7865 EDUCATORS LANE,
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38133-8191
Mailing Address - Country:US
Mailing Address - Phone:901-384-9920
Mailing Address - Fax:901-937-7879
Practice Address - Street 1:3960 KNIGHT ARNOLD RD STE 108
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-3001
Practice Address - Country:US
Practice Address - Phone:901-369-6000
Practice Address - Fax:901-369-6001
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD35471207R00000X
TN35471207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3869544Medicaid
MS02089052Medicaid
TN4044284OtherBCBS OF TN
H53984Medicare UPIN
MS02089052Medicaid
TN3869544Medicaid