Provider Demographics
NPI:1942702915
Name:HEIDARI, OMEID (MSN, ANP-C)
Entity Type:Individual
Prefix:MR
First Name:OMEID
Middle Name:
Last Name:HEIDARI
Suffix:
Gender:M
Credentials:MSN, ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 BOYER ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-2006
Mailing Address - Country:US
Mailing Address - Phone:559-681-6715
Mailing Address - Fax:
Practice Address - Street 1:1717 E MONUMENT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0027
Practice Address - Country:US
Practice Address - Phone:410-955-1725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR218569363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care