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General NPI Number Information
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NPI Number | 1245899186
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Entity Type | Individual
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Provider Name | OMAR KHAYYAM JOHNSON HFA
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Gender | Male
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Dates
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Enumeration Date | 06/12/2019
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Last Update Date | 06/12/2019
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Provider Practice Location Address
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Address Line | 2735 ROTHE LN
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City | INDIANAPOLIS
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State | IN
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Zip | 46229-5517
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Country | US
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Telephone | 317-540-4294
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Fax | 317-434-5908
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Provider Business Mailing Address
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Address Line | 2735 ROTHE LN
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City | INDIANAPOLIS
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State | IN
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Zip | 46229-5517
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Country | US
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Telephone | 317-540-4294
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Fax | 317-434-5908
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 14002332A
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License Number State | IN
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