Healthcare Provider Details

I. General information

NPI: 1346568532
Provider Name (Legal Business Name): OMAR MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WHETSTONE PL STE 204
ST AUGUSTINE FL
32086-5774
US

IV. Provider business mailing address

100 WHETSTONE PL STE 204
ST AUGUSTINE FL
32086-5774
US

V. Phone/Fax

Practice location:
  • Phone: 217-720-3144
  • Fax:
Mailing address:
  • Phone: 217-720-3144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number0097900
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0094907
License Number StateFL

VIII. Authorized Official

Name: WALID OMAR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 217-720-3144