Basic Information
Provider Information | |||||||||
NPI: | 1821049735 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MIRZA | ||||||||
FirstName: | EHSUN | ||||||||
MiddleName: | RAZA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MAHMOOD | ||||||||
OtherFirstName: | AHSAN | ||||||||
OtherMiddleName: | RAZA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 856 J CLYDE MORRIS BLVD STE A | ||||||||
Address2: |   | ||||||||
City: | NEWPORT NEWS | ||||||||
State: | VA | ||||||||
PostalCode: | 236011318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7573165800 | ||||||||
FaxNumber: | 7575345190 | ||||||||
Practice Location | |||||||||
Address1: | 12200 WARWICK BLVD STE 290 | ||||||||
Address2: |   | ||||||||
City: | NEWPORT NEWS | ||||||||
State: | VA | ||||||||
PostalCode: | 236012344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7575345454 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2006 | ||||||||
LastUpdateDate: | 01/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 0101271120 | VA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
ID | Type | State | Issuer | Description | 7010558 | 05 | RI |   | MEDICAID |