Provider Demographics
NPI:1568213395
Name:MIRZA, RIDA FATIMA (MBBS)
Entity type:Individual
Prefix:
First Name:RIDA FATIMA
Middle Name:
Last Name:MIRZA
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2107
Mailing Address - Country:US
Mailing Address - Phone:478-633-1721
Mailing Address - Fax:478-633-2316
Practice Address - Street 1:777 HEMLOCK STREET
Practice Address - Street 2:MSC # 165
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-633-1634
Practice Address - Fax:478-633-1578
Is Sole Proprietor?:No
Enumeration Date:2024-03-29
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15907207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program