MEDICARE: MOHAMED S OMER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	F2764958	CA

General Provider Information

NPI Number	:	1063040509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOHAMED S OMER

Provider Business Mailing Address
First Line	:	6163 UNIVERSITY AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-5720
Country	:	US
Telephone Number	:	619-362-6485
Fax Number	:

Provider Business Practice Location Address
First Line	:	6163 UNIVERSITY AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-5720
Country	:	US
Telephone Number	:	619-362-6485
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2020
Last Update Date	:	05/07/2020

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Directions to “ MOHAMED S OMER ” Practice Location

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