Healthcare Provider Details

I. General information

NPI: 1568039832
Provider Name (Legal Business Name): FARIS ANTHONY MIRZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST # BP4109
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

339 RAILROAD AVE # 1-239
NORTH AUGUSTA SC
29841-3987
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-6100
  • Fax:
Mailing address:
  • Phone: 678-462-9150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number12833
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: