Healthcare Provider Details

I. General information

NPI: 1598696247
Provider Name (Legal Business Name): MOHAMED OMAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 N ROOSEVELT BLVD
KEY WEST FL
33040-3950
US

IV. Provider business mailing address

1589 ANDERSON AVE
FORT LEE NJ
07024-2743
US

V. Phone/Fax

Practice location:
  • Phone: 305-434-9205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number59654
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: