Basic Information
| Provider Information | |||||||||
| NPI: | 1609886647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAHEEM | ||||||||
| FirstName: | MIRZA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 WABASH ST STE 105 | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463604364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198781300 | ||||||||
| FaxNumber: | 2198789764 | ||||||||
| Practice Location | |||||||||
| Address1: | 9850 GENESEE AVE STE 320 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585541212 | ||||||||
| FaxNumber: | 8587951195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 07/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 140215 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100095230C | 05 | IN | MEDICAID |