Provider Demographics
NPI:1770557555
Name:MIRZA, DAN B (MD)
Entity type:Individual
Prefix:DR
First Name:DAN
Middle Name:B
Last Name:MIRZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 52500
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-0125
Mailing Address - Country:US
Mailing Address - Phone:480-855-6292
Mailing Address - Fax:480-855-6293
Practice Address - Street 1:2450 E GUADALUPE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-5116
Practice Address - Country:US
Practice Address - Phone:480-855-6292
Practice Address - Fax:480-855-6293
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ341342084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ943424Medicaid
AZF40688Medicare UPIN
AZ943424Medicaid