Provider Demographics
NPI:1346304607
Name:OMELSKY, PAUL THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:THEODORE
Last Name:OMELSKY
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 1:2460 FAIRMOUNT BLVD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106-3171
Mailing Address - Country:US
Mailing Address - Phone:216-536-8479
Mailing Address - Fax:216-932-7668
Practice Address - Street 1:2460 FAIRMOUNT BLVD
Practice Address - Street 2:SIUTE 212
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44106-3171
Practice Address - Country:US
Practice Address - Phone:216-536-8479
Practice Address - Fax:216-932-7668
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0310252084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0150223Medicaid
OH0150223Medicaid
OH36-4031Medicare ID - Type Unspecified