Provider Demographics
NPI:1245259910
Name:MIRZA, FAROOQ A (MD)
Entity type:Individual
Prefix:DR
First Name:FAROOQ
Middle Name:A
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 1:309 11TH ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:KY
Mailing Address - Zip Code:41008-1435
Mailing Address - Country:US
Mailing Address - Phone:502-732-3799
Mailing Address - Fax:502-732-8551
Practice Address - Street 1:309 11TH ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008-1435
Practice Address - Country:US
Practice Address - Phone:502-732-3799
Practice Address - Fax:502-732-8551
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH44235208600000X
KY20006208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY20006OtherSTATE LICENSE NUMBER
KY64866247Medicaid
KY64866247Medicaid
KY20006OtherSTATE LICENSE NUMBER