Provider Demographics
NPI:1780635557
Name:OMAR DAVID HUSSAMY MD PA
Entity Type:Organization
Organization Name:OMAR DAVID HUSSAMY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-213-9800
Mailing Address - Street 1:PO BOX 643408
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32964-3408
Mailing Address - Country:US
Mailing Address - Phone:772-213-9800
Mailing Address - Fax:772-213-9810
Practice Address - Street 1:1260 37TH ST STE 102
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6567
Practice Address - Country:US
Practice Address - Phone:772-213-9800
Practice Address - Fax:772-213-9810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65456207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL200025538OtherRAILROAD MEDICARE
FL23805OtherBCBS
FL0940280001Medicare NSC
FL23805OtherBCBS