Provider Demographics
NPI:1700811213
Name:MIRZA, FAWZIYA SIDDIQUE (OD)
Entity Type:Individual
Prefix:DR
First Name:FAWZIYA
Middle Name:SIDDIQUE
Last Name:MIRZA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6907 BUGLEDRUM WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4612
Mailing Address - Country:US
Mailing Address - Phone:410-381-2186
Mailing Address - Fax:
Practice Address - Street 1:15785 COLUMBIA PIKE
Practice Address - Street 2:
Practice Address - City:BURTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866-1030
Practice Address - Country:US
Practice Address - Phone:301-421-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTPA1423152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD898969Medicare ID - Type Unspecified
MDU65763Medicare UPIN