Healthcare Provider Details

I. General information

NPI: 1881081685
Provider Name (Legal Business Name): OMAR S WAQHAR D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date: 08/15/2023
Reactivation Date: 08/25/2023

III. Provider practice location address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

7422 S 50TH ST
FRANKLIN WI
53132-7714
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-8000
  • Fax: 260-373-8034
Mailing address:
  • Phone: 928-785-7382
  • Fax: 734-402-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.150172
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number71368
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number02007204A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101021845
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: