Provider Demographics
NPI:1184860421
Name:MIRZAZADEH, MAJID (MD)
Entity Type:Individual
Prefix:
First Name:MAJID
Middle Name:
Last Name:MIRZAZADEH
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 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-0238
Mailing Address - Fax:
Practice Address - Street 1:140 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1522
Practice Address - Country:US
Practice Address - Phone:336-716-4131
Practice Address - Fax:336-713-0328
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-02039208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911056Medicaid
NC2023385Medicare PIN