Provider Demographics
NPI:1104924166
Name:MIRZA, ABDUL M (MD)
Entity type:Individual
Prefix:
First Name:ABDUL
Middle Name:M
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:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-0337
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-2177
Practice Address - Street 1:908 SCARBRO ROAD
Practice Address - Street 2:
Practice Address - City:SCARBRO
Practice Address - State:WV
Practice Address - Zip Code:25917
Practice Address - Country:US
Practice Address - Phone:304-469-2905
Practice Address - Fax:304-465-2177
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV09502207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0078489000Medicaid
WV0078489000Medicaid
WVM10177493Medicare PIN
WVWV0565AMedicare PIN
WV2031512Medicare PIN
WV2031511Medicare PIN