Healthcare Provider Details

I. General information

NPI: 1497711626
Provider Name (Legal Business Name): ALI MIRZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 CAMPUS POINT DR SUITE 2B MAIL CODE 0975
LA JOLLA CA
92037-1300
US

IV. Provider business mailing address

200 W ARBOR DR MC 0840 UCSD MEDICAL CENTER HILLCREST
SAN DIEGO CA
92103-9000
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-8440
  • Fax:
Mailing address:
  • Phone: 858-657-8440
  • Fax: 858-657-8069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35086775
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC54460
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: