Healthcare Provider Details

I. General information

NPI: 1104077312
Provider Name (Legal Business Name): KHAWAJA OWAIS OMAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE STE 700
CHARLESTON WV
25304-1230
US

IV. Provider business mailing address

3100 MACCORKLE AVE SE STE 700
CHARLESTON WV
25304-1230
US

V. Phone/Fax

Practice location:
  • Phone: 304-720-7305
  • Fax:
Mailing address:
  • Phone: 304-720-7305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2014027663
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01069485A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number30789
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: