Provider Demographics
NPI:1235116567
Name:FARUK, OMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name:FARUK
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 1:125 LIBERTY ST 205
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-1109
Mailing Address - Country:US
Mailing Address - Phone:413-271-7136
Mailing Address - Fax:413-271-7137
Practice Address - Street 1:125 LIBERTY ST 205
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1109
Practice Address - Country:US
Practice Address - Phone:413-271-7136
Practice Address - Fax:413-271-7137
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2104181Medicaid
MAJ28861OtherBLUE CROSS BLUE SHIELD
MAJ28861OtherBLUE CROSS BLUE SHIELD
MA2104181Medicaid
MAMX9324Medicare PIN