Individual
SHAZIA MIRZA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1020 35TH ST, KENOSHA, WI 53140-1902
(262) 652-3500
(262) 925-8353
Mailing address
1020 35TH ST, KENOSHA, WI 53140-1902
(262) 652-3500
(262) 925-8353
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036-115477
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0622304
ECFMG NUMBER
—
01
—
1069731001
DIAMOND PROVIDER ID
WI
05
—
34738600
—
WI
01
—
83832
DEAN S.E. MEDICAID
WI
Enumeration date
06/16/2006
Last updated
04/25/2008
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