Provider Demographics
NPI:1619430782
Name:MIRZA, ABDUL-SAMAD
Entity type:Individual
Prefix:
First Name:ABDUL-SAMAD
Middle Name:
Last Name:MIRZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MITCHEL FIELD WAY
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5034
Mailing Address - Country:US
Mailing Address - Phone:631-813-6869
Mailing Address - Fax:
Practice Address - Street 1:107 MITCHEL FIELD WAY
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5034
Practice Address - Country:US
Practice Address - Phone:631-813-6869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS18253204D00000X
NY323388204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty