Healthcare Provider Details

I. General information

NPI: 1568145746
Provider Name (Legal Business Name): JASMINE OMAR HALTAM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 08/14/2023
Certification Date: 08/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7505 OSLER DR STE 208
TOWSON MD
21204-7738
US

IV. Provider business mailing address

137 BEACON RUN
SUFFOLK VA
23435-1375
US

V. Phone/Fax

Practice location:
  • Phone: 410-821-7572
  • Fax:
Mailing address:
  • Phone: 919-758-4495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberC08972
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: