Provider Demographics
NPI:1912516790
Name:CHOUDHURY, OMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name:CHOUDHURY
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 1:2799 W GRAND BLVD HENRY FORD HOSPITAL
Mailing Address - Street 2:DEPARTMENT OF NEUROLOGY, K-11
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-282-7357
Mailing Address - Fax:313-916-3014
Practice Address - Street 1:HENROY FORD HOSPITAL, MEDICAL EDUCATION DEPARTMENT .
Practice Address - Street 2:2799 W. GRAND BOULEVARD
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2585
Practice Address - Fax:313-916-3014
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2021-12-22
Deactivation Date:2021-10-20
Deactivation Code:
Reactivation Date:2021-12-22
Provider Licenses
StateLicense IDTaxonomies
MI4351046352390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program