Healthcare Provider Details

I. General information

NPI: 1619430782
Provider Name (Legal Business Name): ABDUL-SAMAD MIRZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2019
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 MITCHEL FIELD WAY
GARDEN CITY NY
11530-5034
US

IV. Provider business mailing address

107 MITCHEL FIELD WAY
GARDEN CITY NY
11530-5034
US

V. Phone/Fax

Practice location:
  • Phone: 631-813-6869
  • Fax:
Mailing address:
  • Phone: 631-813-6869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberOS18253
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number323388
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: