Provider Demographics
NPI:1477714111
Name:FAWAZ, WALID I (MD)
Entity Type:Individual
Prefix:
First Name:WALID
Middle Name:I
Last Name:FAWAZ
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 1:269 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9337
Mailing Address - Country:US
Mailing Address - Phone:804-861-0700
Mailing Address - Fax:804-863-4626
Practice Address - Street 1:207 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2503
Practice Address - Country:US
Practice Address - Phone:804-541-0918
Practice Address - Fax:804-541-7924
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012435552084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1477714111Medicaid