Provider Demographics
NPI:1043257256
Name:NUSAIREE, MIRZA M (MD)
Entity type:Individual
Prefix:
First Name:MIRZA
Middle Name:M
Last Name:NUSAIREE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 MADISON PARK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-6189
Mailing Address - Country:US
Mailing Address - Phone:410-766-4747
Mailing Address - Fax:410-766-4855
Practice Address - Street 1:1401 MADISON PARK DR
Practice Address - Street 2:SUITE #100
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-766-4747
Practice Address - Fax:410-766-4855
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0040519207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD079341800Medicaid
E71177Medicare UPIN
7984Medicare PIN
MDE71177Medicare UPIN
MD7984Medicare PIN