Healthcare Provider Details

I. General information

NPI: 1841753225
Provider Name (Legal Business Name): MOJTABA MIRZAEI MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 ROBBINS ST
WATERBURY CT
06708-2652
US

IV. Provider business mailing address

64 ROBBINS ST
WATERBURY CT
06708-2613
US

V. Phone/Fax

Practice location:
  • Phone: 203-573-7284
  • Fax: 203-573-7031
Mailing address:
  • Phone: 203-573-6162
  • Fax: 203-573-6707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number70250
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: