Provider Demographics
NPI:1720540347
Name:ATIQ, OSMAN OMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:OSMAN
Middle Name:OMAR
Last Name:ATIQ
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 1:2525 E DATE PALM PASEO APT 2018
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-7625
Mailing Address - Country:US
Mailing Address - Phone:870-718-1994
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST DEPT OF
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2022-08-04
Deactivation Date:2022-06-27
Deactivation Code:
Reactivation Date:2022-08-04
Provider Licenses
StateLicense IDTaxonomies
CAA1792322085R0001X, 208M00000X, 207R00000X
390200000X
ARE-14140207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR233001795Medicaid