Healthcare Provider Details

I. General information

NPI: 1255388948
Provider Name (Legal Business Name): OMER KUCUK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 CLIFTON RD NE
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

1365 CLIFTON RD NE
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 405-778-5903
  • Fax:
Mailing address:
  • Phone: 405-778-5903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301037887
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number061470
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: