Provider Demographics
NPI:1982614665
Name:QIDWAI, ANILA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANILA
Middle Name:
Last Name:QIDWAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FNU
Other - Middle Name:
Other - Last Name:ANILA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1570 OLD ALABAMA RD
Mailing Address - Street 2:SUITE #105
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2108
Mailing Address - Country:US
Mailing Address - Phone:770-676-6838
Mailing Address - Fax:770-676-6840
Practice Address - Street 1:1570 OLD ALABAMA RD
Practice Address - Street 2:SUITE#105
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2108
Practice Address - Country:US
Practice Address - Phone:770-676-6838
Practice Address - Fax:770-676-6840
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065787207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0-634-383-4OtherECFMG#
GA065787OtherGEORGIA LISCENCE
CAI64827Medicare UPIN
CA0-634-383-4OtherECFMG#