Provider Demographics
NPI:1689089401
Name:CWIDA, INC
Entity Type:Organization
Organization Name:CWIDA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOJTAEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-661-2273
Mailing Address - Street 1:4400 W UNIVERSITY BLVD
Mailing Address - Street 2:APT: 10306
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-3876
Mailing Address - Country:US
Mailing Address - Phone:817-729-5793
Mailing Address - Fax:866-292-6489
Practice Address - Street 1:15800 DOOLEY RD STE 170
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-5712
Practice Address - Country:US
Practice Address - Phone:972-661-2273
Practice Address - Fax:866-292-6489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX767459163WG0600X
TXAP125351363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No163WG0600XNursing Service ProvidersRegistered NurseGerontologyGroup - Multi-Specialty