MEDICARE: DR. OMAR IDLIBI MD

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	207ZC0006X	Clinical Pathology Physician	9300397	NC
2	207ZC0500X	Cytopathology Physician	9300397	NC
3	207ZP0101X	Anatomic Pathology Physician	9300397	NC

General Provider Information

NPI Number	:	1962407189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OMAR IDLIBI MD

Provider Business Mailing Address
First Line	:	1815 BACK CREEK DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-2159
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1815 BACK CREEK DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-2159
Country	:	US
Telephone Number	:	704-598-8818
Fax Number	:

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

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	03/12/2019

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