Basic Information
| Provider Information | |||||||||
| NPI: | 1144317785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIZAMI | ||||||||
| FirstName: | MUSHARRAF | ||||||||
| MiddleName: | ASHROF | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56 CLUB MANOR DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810081679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195844767 | ||||||||
| FaxNumber: | 7195844808 | ||||||||
| Practice Location | |||||||||
| Address1: | 56 CLUB MANOR DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810081679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195844767 | ||||||||
| FaxNumber: | 7195844808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 09/27/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 41416 | CO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 78324041 | 05 | CO | MEDICAID |