Provider Demographics
NPI:1104389469
Name:ISMAEEL, OMER (MD)
Entity Type:Individual
Prefix:
First Name:OMER
Middle Name:
Last Name:ISMAEEL
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 1:2307 LAKEHORE DR NORTH
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003
Mailing Address - Country:US
Mailing Address - Phone:904-993-4272
Mailing Address - Fax:
Practice Address - Street 1:2140 KINGSLEY AVE STE 1
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5129
Practice Address - Country:US
Practice Address - Phone:904-368-6809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME162466207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine