Provider Demographics
NPI:1205981578
Name:KHARI A OMOLARA PC
Entity type:Organization
Organization Name:KHARI A OMOLARA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHARI
Authorized Official - Middle Name:ABAYOMI
Authorized Official - Last Name:OMOLARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-573-9471
Mailing Address - Street 1:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39603-7129
Mailing Address - Country:US
Mailing Address - Phone:601-445-1922
Mailing Address - Fax:601-445-1923
Practice Address - Street 1:317 HIGHLAND BLVD STE S
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4636
Practice Address - Country:US
Practice Address - Phone:601-445-1922
Practice Address - Fax:601-445-1923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS176192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126454Medicaid
MS00126454Medicaid
MSH75606Medicare UPIN