Provider Demographics
NPI:1245082205
Name:MIRZA, MOHAMMED YAHYA (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:YAHYA
Last Name:MIRZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 N YORK ST APT 121
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1248
Mailing Address - Country:US
Mailing Address - Phone:630-418-7077
Mailing Address - Fax:630-418-7077
Practice Address - Street 1:9555 S 52ND AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3054
Practice Address - Country:US
Practice Address - Phone:708-422-5700
Practice Address - Fax:708-422-8225
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125084603207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program