Healthcare Provider Details

I. General information

NPI: 1912516790
Provider Name (Legal Business Name): OMAR CHOUDHURY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date: 10/20/2021
Reactivation Date: 12/22/2021

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

2799 W GRAND BLVD HENRY FORD HOSPITAL DEPARTMENT OF NEUROLOGY, K-11
DETROIT MI
48202
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2585
  • Fax: 313-916-3014
Mailing address:
  • Phone: 313-282-7357
  • Fax: 313-916-3014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number79401
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301512388
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: