Healthcare Provider Details

I. General information

NPI: 1063034536
Provider Name (Legal Business Name): OMAR WAHID MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 NEVINS ST SUITE 505
BRIGHTON MA
02135
US

IV. Provider business mailing address

960 MASSACHUSETTS AVENUE FL 2
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1015683
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: