Provider Demographics
NPI:1821049735
Name:MIRZA, EHSUN RAZA (MD)
Entity Type:Individual
Prefix:DR
First Name:EHSUN
Middle Name:RAZA
Last Name:MIRZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AHSAN
Other - Middle Name:RAZA
Other - Last Name:MAHMOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-316-5800
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:12200 WARWICK BLVD STE 290
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-2344
Practice Address - Country:US
Practice Address - Phone:757-534-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101271120207RC0200X
RI10606207RC0200X, 207RN0300X
MA208611207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7010558Medicaid
RI7010558Medicaid
RI007010558Medicare PIN