Healthcare Provider Details

I. General information

NPI: 1629465802
Provider Name (Legal Business Name): OMAR A ABU ANZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2015
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 EVERETT DR # NP2350
OKLAHOMA CITY OK
73104-5047
US

IV. Provider business mailing address

1200 EVERETT DR
OKLAHOMA CITY OK
73104-5047
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5530
  • Fax:
Mailing address:
  • Phone: 452-271-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number38427
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: