Healthcare Provider Details

I. General information

NPI: 1275769978
Provider Name (Legal Business Name): OMAR AL USTWANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 W. SHERMAN AVENUE SUITE 101
VINELAND NJ
08360
US

IV. Provider business mailing address

ELM AND CARLTON ST
BUFFALO NY
14263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 856-696-9550
  • Fax: 856-691-1686
Mailing address:
  • Phone: 716-845-2300
  • Fax: 716-845-8008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08952200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: