Healthcare Provider Details

I. General information

NPI: 1588424113
Provider Name (Legal Business Name): OMAR KHAYAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/20/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 N WATERMAN AVE
SAN BERNARDINO CA
92404-4836
US

IV. Provider business mailing address

735 S ROCK GARDEN CIR
ANAHEIM CA
92808-1442
US

V. Phone/Fax

Practice location:
  • Phone: 909-883-8711
  • Fax:
Mailing address:
  • Phone: 714-576-9985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: