Provider Demographics
NPI:1386105096
Name:MIRZA, FARYAL G (MD)
Entity type:Individual
Prefix:DR
First Name:FARYAL
Middle Name:G
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 1:142 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2922
Mailing Address - Country:US
Mailing Address - Phone:434-799-2225
Mailing Address - Fax:
Practice Address - Street 1:142 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2922
Practice Address - Country:US
Practice Address - Phone:434-799-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116034688207R00000X
390200000X
VA0101275694207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program