Provider Demographics
NPI:1972547040
Name:MIRZA, SHAZIA (MD)
Entity Type:Individual
Prefix:
First Name:SHAZIA
Middle Name:
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 1:1020 35TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-1902
Mailing Address - Country:US
Mailing Address - Phone:262-652-3500
Mailing Address - Fax:262-925-8353
Practice Address - Street 1:1020 35TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-1902
Practice Address - Country:US
Practice Address - Phone:262-652-3500
Practice Address - Fax:262-925-8353
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115477207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI83832OtherDEAN S.E. MEDICAID
WI1069731001OtherDIAMOND PROVIDER ID
WI83832OtherCHILDRENS COMM. HEALTH
WI34738600Medicaid
0622304OtherECFMG NUMBER
WI1069731001OtherDIAMOND PROVIDER ID
WII65779Medicare UPIN
0622304OtherECFMG NUMBER