Provider Demographics
NPI:1801037254
Name:OMIDNIA, BAYA
Entity Type:Individual
Prefix:
First Name:BAYA
Middle Name:
Last Name:OMIDNIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1574
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1574
Mailing Address - Country:US
Mailing Address - Phone:575-627-9500
Mailing Address - Fax:575-624-7537
Practice Address - Street 1:402 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5247
Practice Address - Country:US
Practice Address - Phone:575-627-9500
Practice Address - Fax:575-627-4127
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2009-0514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1932187044OtherMEDICARE GROUP NPI
NM41284399Medicaid
NM800521089OtherMCR GROUP
NMZ2565OtherGROUP MCD
NMNM302299Medicare PIN