Provider Demographics
NPI:1558876912
Name:OMONDI, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:OMONDI
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 1:1021 WENTZVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3437
Mailing Address - Country:US
Mailing Address - Phone:636-787-7685
Mailing Address - Fax:636-856-8377
Practice Address - Street 1:11520 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2704
Practice Address - Country:US
Practice Address - Phone:314-291-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017035193208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice