Provider Demographics
NPI:1912956335
Name:MIRZA, HARIS INAM (MD)
Entity Type:Individual
Prefix:
First Name:HARIS
Middle Name:INAM
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 1:2651 SW 32ND PL
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471
Mailing Address - Country:US
Mailing Address - Phone:352-401-7552
Mailing Address - Fax:352-622-7945
Practice Address - Street 1:2651 SW 32ND PL
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471
Practice Address - Country:US
Practice Address - Phone:352-401-7552
Practice Address - Fax:352-622-7945
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88195207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267672900Medicaid
FL81078OtherBC/BS
FL81078YOtherMEDICARE PTAN
FL81078YOtherMEDICARE PTAN
FL267672900Medicaid