Provider Demographics
NPI:1164996195
Name:MOHAMED, OMAR A
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:A
Last Name:MOHAMED
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 1:450 N 33RD ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3854
Mailing Address - Country:US
Mailing Address - Phone:414-885-8127
Mailing Address - Fax:414-448-6940
Practice Address - Street 1:450 N 33RD ST APT 2
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3854
Practice Address - Country:US
Practice Address - Phone:414-885-8127
Practice Address - Fax:414-448-6940
Is Sole Proprietor?:No
Enumeration Date:2019-01-12
Last Update Date:2019-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIM53064194001-04172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver