MEDICARE: MARIAH SALIM MITHAIWALA DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	5101019980	MI
2	207P00000X	Emergency Medicine Physician	Q4470	TX
3	390200000X	Student in an Organized Health Care Education/Training Program	5101019980	MI
4	207P00000X	Emergency Medicine Physician	02005805A	IN

General Provider Information

NPI Number	:	1578823324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAH SALIM MITHAIWALA DO

Provider Business Mailing Address
First Line	:	4835 LYNDON B JOHNSON FWY STE 900
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75244-6001
Country	:	US
Telephone Number	:	214-460-9268
Fax Number	:

Provider Business Practice Location Address
First Line	:	4835 LBJ FWY STE 900
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75244-6001
Country	:	US
Telephone Number	:	972-520-8124
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2012
Last Update Date	:	01/11/2022

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