=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710067822
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMMED AZHER MIRZA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2006
-----------------------------------------------------
Last Update Date | 02/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4045 NE LAKEWOOD WAY STE 130
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64064-1995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-228-5335
-----------------------------------------------------
Fax | 816-228-7663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4045 NE LAKEWOOD WAY STE 130
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64064-1995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-228-5335
-----------------------------------------------------
Fax | 816-228-7663
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | R1C10
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------