MEDICARE: WAQAR U. MIRZA M.D.

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	2084N0400X	Neurology Physician	R4N72	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	214050163	OTHER		MEDICARE DEPAUL/SSM HC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750329611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAQAR U. MIRZA M.D.

Provider Business Mailing Address
First Line	:	12266 DE PAUL DR
Second Line	:	SUITE 225
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2514
Country	:	US
Telephone Number	:	314-344-7555
Fax Number	:	314-344-7665

Provider Business Practice Location Address
First Line	:	12266 DE PAUL DRIVE
Second Line	:	SUITE 225
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2514
Country	:	US
Telephone Number	:	314-881-2700
Fax Number	:	314-881-2706

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

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	08/14/2008

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