=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427082031
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULNAZ MIRZA MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4915 S CONGRESS AVE SUITE D
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-964-1411
-----------------------------------------------------
Fax | 561-964-3039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 HAMILTON TERRACE
-----------------------------------------------------
City | ROYAL PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GULNAZ MIRZA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-964-1411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | ME76874
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------