Provider Demographics
NPI:1467422097
Name:KHADRA M OSMAN M D P A
Entity Type:Organization
Organization Name:KHADRA M OSMAN M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHADRA
Authorized Official - Middle Name:MOHAMOUD
Authorized Official - Last Name:OSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-832-0055
Mailing Address - Street 1:1625 SE 3RD AVE
Mailing Address - Street 2:400
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2521
Mailing Address - Country:US
Mailing Address - Phone:954-832-0055
Mailing Address - Fax:954-832-0262
Practice Address - Street 1:1625 SE 3RD AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2521
Practice Address - Country:US
Practice Address - Phone:954-832-0055
Practice Address - Fax:954-832-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2010-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060084261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370049600Medicaid
FLK1971Medicare ID - Type Unspecified
FL370049600Medicaid
FLE41461Medicare UPIN