Provider Demographics
NPI:1275220543
Name:ELMANDOUH, OMAR (MD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:ELMANDOUH
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 1:1701 SAN PABLO RD S APT 1121
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-3829
Mailing Address - Country:US
Mailing Address - Phone:904-469-3292
Mailing Address - Fax:
Practice Address - Street 1:1701 SAN PABLO RD S APT 1121
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-3829
Practice Address - Country:US
Practice Address - Phone:904-469-3292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program