Healthcare Provider Details

I. General information

NPI: 1710533104
Provider Name (Legal Business Name): OMAR AUNI ISSA KHOZOUZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 07/31/2021
Certification Date: 07/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-9400
  • Fax: 434-982-1618
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number0101270431
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: