Healthcare Provider Details

I. General information

NPI: 1437159597
Provider Name (Legal Business Name): NADEEM M MIRZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 11/27/2023
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 HAZEN ST SUITE 104
PAW PAW MI
49079-1040
US

IV. Provider business mailing address

404 HAZEN ST SUITE 104
PAW PAW MI
49079-1040
US

V. Phone/Fax

Practice location:
  • Phone: 269-657-1595
  • Fax: 269-657-1534
Mailing address:
  • Phone: 269-657-1595
  • Fax: 269-657-1534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301086227
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: