Healthcare Provider Details

I. General information

NPI: 1184712333
Provider Name (Legal Business Name): FAZAL-UR-RAHMAN MIRZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17707 STUDEBAKER RD
CERRITOS CA
90703-2640
US

IV. Provider business mailing address

6042 MARILYN DR
CYPRESS CA
90630-3944
US

V. Phone/Fax

Practice location:
  • Phone: 562-402-0688
  • Fax: 562-402-3032
Mailing address:
  • Phone: 714-826-0505
  • Fax: 562-402-3032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA32119
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: