Provider Demographics
NPI:1699785212
Name:MIRZA, WAJAHAT ALI (MD)
Entity type:Individual
Prefix:DR
First Name:WAJAHAT
Middle Name:ALI
Last Name:MIRZA
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 1:404 HOGANS RUN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-3370
Mailing Address - Country:US
Mailing Address - Phone:803-556-4207
Mailing Address - Fax:
Practice Address - Street 1:6000 FAIRVIEW RD
Practice Address - Street 2:SUITE 1200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-2224
Practice Address - Country:US
Practice Address - Phone:803-556-4207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC219852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
3430Medicare ID - Type Unspecified
H348336719Medicare PIN