Basic Information
| Provider Information | |||||||||
| NPI: | 1063690691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRZA | ||||||||
| FirstName: | TAHIRA | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 FOGG RD | ||||||||
| Address2: | COASTAL MEDICAL ASSOCIATES | ||||||||
| City: | SOUTH WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021902432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816248000 | ||||||||
| FaxNumber: | 7818786750 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 FOGG RD | ||||||||
| Address2: | |||||||||
| City: | WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021902432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817924121 | ||||||||
| FaxNumber: | 7818786750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2008 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036-119777 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 042481 | CT | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | 4301072064 | MI | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | 257617 | MA | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 036119777 | 05 | IL | MEDICAID |