Provider Demographics
NPI:1093040115
Name:KLOBOCISTA, OMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name:KLOBOCISTA
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 1:220 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2919
Mailing Address - Country:US
Mailing Address - Phone:856-524-2531
Mailing Address - Fax:
Practice Address - Street 1:220 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2919
Practice Address - Country:US
Practice Address - Phone:856-524-2531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08645900207Q00000X
NY255828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine