Provider Demographics
NPI:1588612550
Name:OMAR, MOHAMMAD MASIHUDDIN (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:MASIHUDDIN
Last Name:OMAR
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 1:185 GENESEE ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2199
Mailing Address - Country:US
Mailing Address - Phone:315-793-8806
Mailing Address - Fax:315-793-8046
Practice Address - Street 1:185 GENESEE ST
Practice Address - Street 2:SUITE 600
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-2199
Practice Address - Country:US
Practice Address - Phone:315-793-8806
Practice Address - Fax:315-793-8046
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1266212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY126621-2OtherWC
NY225115OtherMVP
NY10024325OtherCDPHP
NY040426014046OtherFIDELIS
NYP010126621OtherBCBS
NY0086963OtherGHI
NY300021947OtherRAIL ROAD MEDICARE
NY00596667Medicaid
NY040426014046OtherFIDELIS
B82289Medicare UPIN