Healthcare Provider Details

I. General information

NPI: 1902856578
Provider Name (Legal Business Name): SHAKEELA F MIRZA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46591 ROMEO PLANK RD SUITE 205
MACOMB MI
48044-5742
US

IV. Provider business mailing address

46591 ROMEO PLANK RD SUITE 205
MACOMB MI
48044-5742
US

V. Phone/Fax

Practice location:
  • Phone: 586-226-6250
  • Fax: 586-226-6255
Mailing address:
  • Phone: 586-226-6250
  • Fax: 586-226-6255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301064234
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number4301064234
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: