Provider Demographics
NPI:1457606014
Name:MIRZA, MUQTADIR A (MD)
Entity Type:Individual
Prefix:
First Name:MUQTADIR
Middle Name:A
Last Name:MIRZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:AMIR
Other - Middle Name:
Other - Last Name:MIRZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3200 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1227
Mailing Address - Country:US
Mailing Address - Phone:304-388-1020
Mailing Address - Fax:
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program