Provider Demographics
NPI:1265069876
Name:KIDWAI, HUMZA (OD)
Entity type:Individual
Prefix:
First Name:HUMZA
Middle Name:
Last Name:KIDWAI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:5405 WILLIAMSPORT PIKE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-6495
Practice Address - Country:US
Practice Address - Phone:304-263-4000
Practice Address - Fax:304-263-4004
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2076-IOD152W00000X
MDTA2785152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist