MEDICARE: DR. OMID OMIDVAR M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	A55552	CA

General Provider Information

NPI Number	:	1184678583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OMID OMIDVAR M.D.

Provider Business Mailing Address
First Line	:	3791 KATELLA AVE
Second Line	:	SUITE 106
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-3105
Country	:	US
Telephone Number	:	562-430-3114
Fax Number	:	562-430-7718

Provider Business Practice Location Address
First Line	:	3791 KATELLA AVE
Second Line	:	SUITE 106
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-3105
Country	:	US
Telephone Number	:	562-430-3114
Fax Number	:	562-430-7718

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	04/28/2011

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