Healthcare Provider Details

I. General information

NPI: 1376573204
Provider Name (Legal Business Name): IMRAN A MIRZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 COOPER ST
DEPTFORD NJ
08096-3014
US

IV. Provider business mailing address

PO BOX 69
MICKLETON NJ
08056-0069
US

V. Phone/Fax

Practice location:
  • Phone: 856-848-8060
  • Fax:
Mailing address:
  • Phone: 856-381-9598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08024700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD431989
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number25MA08024700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: