Provider Demographics
NPI:1326553843
Name:MESA, OMAR R
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:R
Last Name:MESA
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 1:374 SW 16TH TER
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-6627
Mailing Address - Country:US
Mailing Address - Phone:786-488-1830
Mailing Address - Fax:
Practice Address - Street 1:374 SW 16TH TER
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-6627
Practice Address - Country:US
Practice Address - Phone:786-488-1830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19102206106S00000X
FLMA48822225700000X
FL1-20-45171103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA48822OtherMASSAGE THERAPIST