Healthcare Provider Details

I. General information

NPI: 1992949770
Provider Name (Legal Business Name): OMKAR HEMANT DAVE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

IV. Provider business mailing address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

V. Phone/Fax

Practice location:
  • Phone: 601-949-9106
  • Fax: 601-914-1835
Mailing address:
  • Phone: 601-949-9106
  • Fax: 601-914-1835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0034792
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number23122
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: