Provider Demographics
NPI:1457349888
Name:MIRZA, WAJID A (DO)
Entity Type:Individual
Prefix:
First Name:WAJID
Middle Name:A
Last Name:MIRZA
Suffix:
Gender:M
Credentials:DO
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 58294
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-8294
Mailing Address - Country:US
Mailing Address - Phone:281-942-8001
Mailing Address - Fax:281-724-1919
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4220
Practice Address - Country:US
Practice Address - Phone:281-942-8001
Practice Address - Fax:281-724-1919
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9365207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170326601Medicaid
TX8K8336OtherBC/BS OF TEXAS
TX170326603Medicaid
TX8DL798OtherBCBSTX
TXP01554524OtherRRMEDICARE
TX170326603Medicaid
TXTXB127989Medicare PIN
TX8DL798OtherBCBSTX
I22243Medicare UPIN