Provider Demographics
NPI:1245231570
Name:MIRZA, WAJAHAT (MD)
Entity Type:Individual
Prefix:
First Name:WAJAHAT
Middle Name:
Last Name:MIRZA
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 1:1170 E BELVIDERE RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2061
Mailing Address - Country:US
Mailing Address - Phone:847-543-6814
Mailing Address - Fax:847-543-0787
Practice Address - Street 1:1170 E BELVIDERE RD
Practice Address - Street 2:SUITE 212
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2061
Practice Address - Country:US
Practice Address - Phone:847-543-6814
Practice Address - Fax:847-543-0787
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF94476Medicare UPIN
IL200249Medicare ID - Type Unspecified