Provider Demographics
NPI:1386056695
Name:WARDI, MIRAIE (DO)
Entity type:Individual
Prefix:
First Name:MIRAIE
Middle Name:
Last Name:WARDI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 WILLIAM D TATE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8755
Mailing Address - Country:US
Mailing Address - Phone:817-488-6812
Mailing Address - Fax:817-251-1303
Practice Address - Street 1:2425 HIGHWAY 121 STE 201
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5011
Practice Address - Country:US
Practice Address - Phone:817-283-5166
Practice Address - Fax:817-283-5176
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS2196207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program