Provider Demographics
NPI:1841241494
Name:CANOSA, OMAR (MD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:CANOSA
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 1:37 KINGS RD
Mailing Address - Street 2:STE 202
Mailing Address - City:MADISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07940-2500
Mailing Address - Country:US
Mailing Address - Phone:973-520-8848
Mailing Address - Fax:973-200-8088
Practice Address - Street 1:37 KINGS RD
Practice Address - Street 2:STE 202
Practice Address - City:MADISON
Practice Address - State:NJ
Practice Address - Zip Code:07940-2500
Practice Address - Country:US
Practice Address - Phone:973-520-8848
Practice Address - Fax:973-200-8088
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4274342084P0800X
NJ25MA083818002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA08381800OtherLICENSE NUMBER
PAMD427434OtherLICENSE NUMBER