Provider Demographics
NPI:1245899186
Name:JOHNSON, OMAR KHAYYAM (HFA)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:KHAYYAM
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:HFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2735 ROTHE LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-5517
Mailing Address - Country:US
Mailing Address - Phone:317-540-4294
Mailing Address - Fax:317-434-5908
Practice Address - Street 1:2735 ROTHE LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-5517
Practice Address - Country:US
Practice Address - Phone:317-540-4294
Practice Address - Fax:317-434-5908
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN14002332A251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management