Provider Demographics
NPI:1912191818
Name:WANI, JAVAID H (MD)
Entity Type:Individual
Prefix:
First Name:JAVAID
Middle Name:H
Last Name:WANI
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:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:2544 COURT DR STE A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3450
Practice Address - Country:US
Practice Address - Phone:704-671-6400
Practice Address - Fax:704-671-6449
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2019-02718207RE0101X
LAMD.201571207R00000X
SC32116207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1002682Medicaid
SC321164Medicaid
LA4K873Medicare PIN
SCAA41486072Medicare PIN