Healthcare Provider Details

I. General information

NPI: 1942539945
Provider Name (Legal Business Name): OMAR MINWALLA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2009
Last Update Date: 12/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S BEVERLY DR STE 316
BEVERLY HILLS CA
90212-4405
US

IV. Provider business mailing address

400 S BEVERLY DR STE 316
BEVERLY HILLS CA
90212-4405
US

V. Phone/Fax

Practice location:
  • Phone: 310-286-1300
  • Fax: 310-286-1330
Mailing address:
  • Phone: 310-286-1300
  • Fax: 310-286-1330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number20244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: