Provider Demographics
NPI:1063690691
Name:MIRZA, TAHIRA F (MD)
Entity type:Individual
Prefix:
First Name:TAHIRA
Middle Name:F
Last Name:MIRZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FOGG RD
Mailing Address - Street 2:COASTAL MEDICAL ASSOCIATES
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-2432
Mailing Address - Country:US
Mailing Address - Phone:781-624-8000
Mailing Address - Fax:781-878-6750
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2432
Practice Address - Country:US
Practice Address - Phone:781-792-4121
Practice Address - Fax:781-878-6750
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-119777208600000X
CT0424812086S0102X
MI43010720642086S0102X
MA2576172086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036119777Medicaid
CTPENDINGMedicaid
IL256510Medicare PIN
CTPENDINGMedicaid
ILK49919Medicare PIN