Provider Demographics
NPI:1093255952
Name:WAZZAN, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:WAZZAN
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 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-4055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3030 HARDEN BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-7952
Practice Address - Country:US
Practice Address - Phone:863-284-6809
Practice Address - Fax:863-284-6810
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1272442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology