Provider Demographics
NPI:1720428915
Name:MAATOUK, OMAR (MD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:MAATOUK
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 1:4129 N HIGHWAY 67
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-2825
Mailing Address - Country:US
Mailing Address - Phone:314-355-6390
Mailing Address - Fax:
Practice Address - Street 1:4129 N HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034-2825
Practice Address - Country:US
Practice Address - Phone:314-355-6390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10011752208000000X, 208D00000X
LA390200000X
MO2019039182208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program