Provider Demographics
NPI:1821290164
Name:MIRZA, ISHRAT ALI (MD)
Entity Type:Individual
Prefix:DR
First Name:ISHRAT
Middle Name:ALI
Last Name:MIRZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 CHURCH RD STE 101
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-8943
Mailing Address - Country:US
Mailing Address - Phone:630-315-6900
Mailing Address - Fax:630-315-6919
Practice Address - Street 1:2635 CHURCH RD STE 101
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60502-8943
Practice Address - Country:US
Practice Address - Phone:630-315-6900
Practice Address - Fax:630-315-6919
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036127593207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1099732Medicaid