Provider Demographics
NPI:1184678583
Name:OMIDVAR, OMID (MD)
Entity Type:Individual
Prefix:DR
First Name:OMID
Middle Name:
Last Name:OMIDVAR
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 1:3791 KATELLA AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3105
Mailing Address - Country:US
Mailing Address - Phone:562-430-3114
Mailing Address - Fax:562-430-7718
Practice Address - Street 1:3791 KATELLA AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3105
Practice Address - Country:US
Practice Address - Phone:562-430-3114
Practice Address - Fax:562-430-7718
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA555522084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG76558Medicare UPIN
CAWA55552AMedicare PIN