Provider Demographics
NPI:1063466845
Name:OMAR, WALID (MD)
Entity Type:Individual
Prefix:DR
First Name:WALID
Middle Name:
Last Name:OMAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WHETSTONE PL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5774
Mailing Address - Country:US
Mailing Address - Phone:217-720-3144
Mailing Address - Fax:904-404-8447
Practice Address - Street 1:100 WHETSTONE PL
Practice Address - Street 2:SUITE 204
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5774
Practice Address - Country:US
Practice Address - Phone:217-720-3144
Practice Address - Fax:904-404-8447
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94907207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274865700Medicaid
FLU7779ZMedicare PIN
FL274865700Medicaid