Provider Demographics
NPI:1871240473
Name:MADISON, OMAR DWAN (SW)
Entity Type:Individual
Prefix:MR
First Name:OMAR
Middle Name:DWAN
Last Name:MADISON
Suffix:
Gender:M
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 CARPENTER ST STE 207
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-2771
Mailing Address - Country:US
Mailing Address - Phone:313-826-0171
Mailing Address - Fax:313-733-4585
Practice Address - Street 1:3120 CARPENTER ST STE 207
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-2771
Practice Address - Country:US
Practice Address - Phone:313-826-0171
Practice Address - Fax:313-733-4585
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator