Provider Demographics
NPI:1659480747
Name:MIRZA-GRUBER, MANIZEH (MD)
Entity type:Individual
Prefix:
First Name:MANIZEH
Middle Name:
Last Name:MIRZA-GRUBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANIZEH
Other - Middle Name:
Other - Last Name:MIRZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6800 PARK TEN BLVD STE 200S
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-4293
Mailing Address - Country:US
Mailing Address - Phone:210-261-1060
Mailing Address - Fax:210-261-1821
Practice Address - Street 1:1 HAVEN FOR HOPE WAY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-1266
Practice Address - Country:US
Practice Address - Phone:210-261-1437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ43572084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX188429801Medicaid
TX188429801Medicaid
TXP00458742Medicare PIN