Provider Demographics
NPI:1881915619
Name:GAYASADDIN, OMAR (DO)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:GAYASADDIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11945 SAN JOSE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-396-4893
Practice Address - Street 1:7051 SOUTHPOINT PKWY S STE 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8713
Practice Address - Country:US
Practice Address - Phone:904-398-2720
Practice Address - Fax:904-398-6408
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13365207W00000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma SpecialistGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNS468OtherMEDICARE
FLQ00073252OtherRAILROAD MEDICARE
FL150K9OtherBCBS-FL