Healthcare Provider Details

I. General information

NPI: 1679886394
Provider Name (Legal Business Name): FAZIA AHMED MIR M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2010
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

888 DIEHNWELLS DR
SAINT LOUIS MO
63119-5456
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-1476
  • Fax:
Mailing address:
  • Phone: 316-990-7007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2010019841
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD2016-0892
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: