Provider Demographics
NPI:1184106908
Name:MIR, MUBARIK N
Entity type:Individual
Prefix:MR
First Name:MUBARIK
Middle Name:N
Last Name:MIR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 ARCH ST # 1
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-4317
Mailing Address - Country:US
Mailing Address - Phone:203-235-6527
Mailing Address - Fax:203-440-4438
Practice Address - Street 1:428 BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-5846
Practice Address - Country:US
Practice Address - Phone:203-235-6527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1226344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1226OtherTAXI
CT1226Medicaid