Healthcare Provider Details

I. General information

NPI: 1962474742
Provider Name (Legal Business Name): KARAN OMIDVARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 PROSPECT AVE STE 204
HACKENSACK NJ
07601-2570
US

IV. Provider business mailing address

170 E 87TH ST APT W11A
NEW YORK NY
10128-2238
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-9190
  • Fax:
Mailing address:
  • Phone: 201-967-8425
  • Fax: 201-263-4665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number219979
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number219979
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number219979
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMA56381
License Number StateNJ
# 5
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number139772
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier80187
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier25MA05638100
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerSTATE LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: