Provider Demographics
NPI:1144208174
Name:OMAR, TARIQ (MD)
Entity Type:Individual
Prefix:DR
First Name:TARIQ
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:PO BOX 673968
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0001
Mailing Address - Country:US
Mailing Address - Phone:734-462-0340
Mailing Address - Fax:734-462-0344
Practice Address - Street 1:26245 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-4546
Practice Address - Country:US
Practice Address - Phone:248-327-7634
Practice Address - Fax:248-327-7641
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070276207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MITO070276OtherBLUE CROSS LICENSE #
MI104501587Medicaid
MITO070276OtherBLUE CROSS LICENSE #