Provider Demographics
NPI:1003262668
Name:MIR, IZZA (DO)
Entity type:Individual
Prefix:
First Name:IZZA
Middle Name:
Last Name:MIR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-5412
Mailing Address - Fax:
Practice Address - Street 1:1000 1ST DR NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-2941
Practice Address - Country:US
Practice Address - Phone:507-433-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT017043207R00000X
MN72609207R00000X
MDH0100219207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine