Provider Demographics
NPI:1285680371
Name:ROWSHAN, OMID (MD)
Entity Type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:ROWSHAN
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 1:1 FEDERAL ST STE SW200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1155
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:1 COOPER PLZ
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103
Practice Address - Country:US
Practice Address - Phone:856-356-4924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046380L207P00000X
NJ25MA07055100207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001284570Medicaid
E77324Medicare UPIN
PA001284570Medicaid