Provider Demographics
NPI:1104914894
Name:MIRZA, VICTORIA M (MD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:M
Last Name:MIRZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:M
Other - Last Name:ETTINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 231189
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92023-1189
Mailing Address - Country:US
Mailing Address - Phone:760-230-2251
Mailing Address - Fax:760-230-2253
Practice Address - Street 1:354 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024
Practice Address - Country:US
Practice Address - Phone:760-230-2251
Practice Address - Fax:760-230-2253
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87119207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02601783Medicaid
NYRB5409Medicare PIN
NYI09948Medicare UPIN