Healthcare Provider Details

I. General information

NPI: 1750382834
Provider Name (Legal Business Name): OMAR S KHOKHAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 E MAIN STREET RD
ATTICA NY
14011-9506
US

IV. Provider business mailing address

PO BOX 265 3325 E MAIN ST
ATTICA NY
14011-0265
US

V. Phone/Fax

Practice location:
  • Phone: 585-591-0800
  • Fax: 585-591-4204
Mailing address:
  • Phone: 585-591-0800
  • Fax: 585-591-4204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number140294
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: