Provider Demographics
NPI:1407237480
Name:HARRIS, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:HARRIS
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 1:26 RIVER POINTE DR S
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-5451
Mailing Address - Country:US
Mailing Address - Phone:305-812-9108
Mailing Address - Fax:855-441-4642
Practice Address - Street 1:9802 HOSIER ST UNIT C
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-4219
Practice Address - Country:US
Practice Address - Phone:757-772-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA61768526172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver