Provider Demographics
NPI:1750329611
Name:MIRZA, WAQAR U (MD)
Entity Type:Individual
Prefix:
First Name:WAQAR
Middle Name:U
Last Name:MIRZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12266 DE PAUL DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2514
Mailing Address - Country:US
Mailing Address - Phone:314-344-7555
Mailing Address - Fax:314-344-7665
Practice Address - Street 1:12266 DE PAUL DRIVE
Practice Address - Street 2:SUITE 225
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2514
Practice Address - Country:US
Practice Address - Phone:314-881-2700
Practice Address - Fax:314-881-2706
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR4N722084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202871018Medicaid
214050163OtherMEDICARE DEPAUL/SSM HC
MO202871018Medicaid
MO000000566Medicare PIN