Provider Demographics
NPI:1851820922
Name:MIRZA MEDICAL PA
Entity Type:Organization
Organization Name:MIRZA MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHURRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-335-5500
Mailing Address - Street 1:3021 NE 44TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-5307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3075 NW 35TH AVE
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33311-1107
Practice Address - Country:US
Practice Address - Phone:305-891-8850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty