1982614665 NPI number — DR. ANILA QIDWAI MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982614665 NPI number — DR. ANILA QIDWAI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QIDWAI
Provider First Name:
ANILA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANILA
Provider Other First Name:
FNU
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982614665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1570 OLD ALABAMA RD
Provider Second Line Business Mailing Address:
SUITE #105
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30076-2108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-676-6838
Provider Business Mailing Address Fax Number:
770-676-6840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1570 OLD ALABAMA RD
Provider Second Line Business Practice Location Address:
SUITE#105
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30076-2108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-676-6838
Provider Business Practice Location Address Fax Number:
770-676-6840
Provider Enumeration Date:
08/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  065787 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0-634-383-4 . This is a "ECFMG#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 065787 . This is a "GEORGIA LISCENCE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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