Healthcare Provider Details

I. General information

NPI: 1376757617
Provider Name (Legal Business Name): M A MIRZA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date: 08/14/2008
Reactivation Date: 05/14/2013

III. Provider practice location address

4045 NE LAKEWOOD WAY SUITE 130
LEES SUMMIT MO
64064-1799
US

IV. Provider business mailing address

4045 NE LAKEWOOD WAY SUITE 130
LEES SUMMIT MO
64064-1799
US

V. Phone/Fax

Practice location:
  • Phone: 816-886-2184
  • Fax: 816-886-2397
Mailing address:
  • Phone: 816-886-2184
  • Fax: 816-886-2397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberRICIO
License Number StateMO

VIII. Authorized Official

Name: DR. MOHAMMED AZHER MIRZA
Title or Position: OWNER
Credential: M.D.
Phone: 816-228-5335