Healthcare Provider Details

I. General information

NPI: 1205409398
Provider Name (Legal Business Name): OMAR AL-RUSAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 18TH ST E
TIFTON GA
31794-3648
US

IV. Provider business mailing address

PO BOX 2650
TIFTON GA
31793-2650
US

V. Phone/Fax

Practice location:
  • Phone: 229-382-7120
  • Fax: 229-353-7779
Mailing address:
  • Phone: 229-402-0425
  • Fax: 229-391-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number13345
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: