Basic Information
| Provider Information | |||||||||
| NPI: | 1386684280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRSON | ||||||||
| FirstName: | SOFIYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 811 SUNSET RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BURLINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080163645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093879242 | ||||||||
| FaxNumber: | 6093879408 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 S CHESTER AVE STE A | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | DELRAN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080751272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567642500 | ||||||||
| FaxNumber: | 8567648335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD426536 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 25MA07944800 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0315931 | 05 | NJ | MEDICAID | 101290599 | 05 | PA | MEDICAID |