Provider Demographics
NPI:1073946554
Name:OMER, AHMED AWADALLA
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:AWADALLA
Last Name:OMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-2419
Mailing Address - Country:US
Mailing Address - Phone:443-864-1998
Mailing Address - Fax:
Practice Address - Street 1:1303 W 5TH ST
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-2419
Practice Address - Country:US
Practice Address - Phone:443-864-1998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ343000Medicare Oscar/Certification