Provider Demographics
NPI:1669601159
Name:TIPU, OMER KHALIQUE (MD)
Entity type:Individual
Prefix:DR
First Name:OMER
Middle Name:KHALIQUE
Last Name:TIPU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 MCDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-2212
Mailing Address - Country:US
Mailing Address - Phone:718-972-4200
Mailing Address - Fax:718-972-6861
Practice Address - Street 1:446 MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-2212
Practice Address - Country:US
Practice Address - Phone:718-972-4200
Practice Address - Fax:718-972-6861
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252322207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03278764Medicaid
NYA400105650Medicare PIN