Provider Demographics
NPI:1447243886
Name:MIRZAI, THOMAS (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MIRZAI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E BELL RD
Mailing Address - Street 2:4400
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2122
Mailing Address - Country:US
Mailing Address - Phone:602-788-7211
Mailing Address - Fax:602-788-1890
Practice Address - Street 1:3815 E BELL RD
Practice Address - Street 2:4400
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2122
Practice Address - Country:US
Practice Address - Phone:602-788-7211
Practice Address - Fax:602-788-1890
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6865207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA892598Medicaid
CA892598Medicaid
CAZ80732Medicare PIN