Provider Demographics
NPI:1669662805
Name:MIRZA, RAEESA WAJAHAT (MD)
Entity Type:Individual
Prefix:DR
First Name:RAEESA
Middle Name:WAJAHAT
Last Name:MIRZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 IRVING ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-3017
Mailing Address - Country:US
Mailing Address - Phone:202-877-7000
Mailing Address - Fax:
Practice Address - Street 1:600 MOYE BLVD
Practice Address - Street 2:ECU PHYSICIANS
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4300
Practice Address - Country:US
Practice Address - Phone:252-744-3258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-01504207R00000X
DCMD210002471207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910778Medicaid
NC5910778Medicaid