Healthcare Provider Details

I. General information

NPI: 1508397613
Provider Name (Legal Business Name): OMAR IQBAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST # BA-2720
AUGUSTA GA
30912-4228
US

IV. Provider business mailing address

1120 15TH ST # BA-2720
AUGUSTA GA
30912-4228
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-1160
  • Fax: 706-721-1158
Mailing address:
  • Phone: 706-721-1160
  • Fax: 706-721-1158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number309276
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number89366
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: