Healthcare Provider Details

I. General information

NPI: 1538706825
Provider Name (Legal Business Name): MTO PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 ELM AVE FL 3
HACKENSACK NJ
07601-4702
US

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier25MA05638100
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerSTATE LICENSE

VIII. Authorized Official

Name: DR. KARAN OMIDVARI
Title or Position: OWNER
Credential: MD
Phone: 201-967-8425