Healthcare Provider Details

I. General information

NPI: 1669662805
Provider Name (Legal Business Name): RAEESA WAJAHAT MIRZA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MOYE BLVD ECU PHYSICIANS
GREENVILLE NC
27834-4300
US

IV. Provider business mailing address

110 IRVING ST NW
WASHINGTON DC
20010-3017
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-3258
  • Fax:
Mailing address:
  • Phone: 202-877-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2008-01504
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD210002471
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: