Healthcare Provider Details

I. General information

NPI: 1669097770
Provider Name (Legal Business Name): NIVIN A OMAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE
ATLANTA GA
30322-1059
US

IV. Provider business mailing address

2315 MALONE WAY
EVANS GA
30809-5313
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-5227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SM0001X
TaxonomyMolecular Genetic Pathology (Medical Genetics) Physician
License Number104094
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number104094
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: