Provider Demographics
NPI:1710067822
Name:MIRZA, MOHAMMED AZHER (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:AZHER
Last Name:MIRZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:M A
Other - Middle Name:
Other - Last Name:MIRZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4045 NE LAKEWOOD WAY
Mailing Address - Street 2:STE 130
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-1995
Mailing Address - Country:US
Mailing Address - Phone:816-228-5335
Mailing Address - Fax:816-228-7663
Practice Address - Street 1:4045 NE LAKEWOOD WAY
Practice Address - Street 2:STE 130
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-1995
Practice Address - Country:US
Practice Address - Phone:816-228-5335
Practice Address - Fax:816-228-7663
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1C102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4861001OtherMEDICARE ID
MO10731160OtherBCBS OF KC
MOH201651387Medicaid
MO0006543BOtherMEDICARE ID
KS100419680AOtherMEDICAID
MO0006543BOtherMEDICARE ID