Healthcare Provider Details

I. General information

NPI: 1184980591
Provider Name (Legal Business Name): KANWAL QIDWAI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 ADELINE ST
OAKLAND CA
94607-2608
US

IV. Provider business mailing address

4835 BARNDANCE ST
FREMONT CA
94555-3523
US

V. Phone/Fax

Practice location:
  • Phone: 713-449-3536
  • Fax:
Mailing address:
  • Phone: 713-449-3536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number133754
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberCA
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: