Healthcare Provider Details

I. General information

NPI: 1982614665
Provider Name (Legal Business Name): ANILA QIDWAI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: FNU ANILA MD

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 OLD ALABAMA RD SUITE#105
ROSWELL GA
30076-2108
US

IV. Provider business mailing address

1570 OLD ALABAMA RD SUITE #105
ROSWELL GA
30076-2108
US

V. Phone/Fax

Practice location:
  • Phone: 770-676-6838
  • Fax: 770-676-6840
Mailing address:
  • Phone: 770-676-6838
  • Fax: 770-676-6840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number065787
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: