Provider Demographics
NPI:1124052014
Name:MIR, ABDUL BASIT (MD)
Entity type:Individual
Prefix:
First Name:ABDUL
Middle Name:BASIT
Last Name:MIR
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 1:131 E REDSTONE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5326
Mailing Address - Country:US
Mailing Address - Phone:850-682-5174
Mailing Address - Fax:850-689-3653
Practice Address - Street 1:131 E REDSTONE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5326
Practice Address - Country:US
Practice Address - Phone:850-682-5174
Practice Address - Fax:850-689-3653
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0032883207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038080600Medicaid
FLD54990Medicare UPIN
FL47030Medicare PIN