Provider Demographics
NPI:1902856578
Name:MIRZA, SHAKEELA F (MD)
Entity Type:Individual
Prefix:
First Name:SHAKEELA
Middle Name:F
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 1:46591 ROMEO PLANK RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5742
Mailing Address - Country:US
Mailing Address - Phone:586-226-6250
Mailing Address - Fax:586-226-6255
Practice Address - Street 1:46591 ROMEO PLANK RD
Practice Address - Street 2:SUITE 205
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5742
Practice Address - Country:US
Practice Address - Phone:586-226-6250
Practice Address - Fax:586-226-6255
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064234208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3383980Medicaid
MI4172282Medicaid
MI0E011720OtherBCBS GROUP NUMBER
MI3383980Medicaid
MI0M92510Medicare PIN
MIM92510007Medicare PIN