Provider Demographics
NPI:1912992983
Name:OMER H WHARTON-ALI MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:OMER H WHARTON-ALI MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OMER
Authorized Official - Middle Name:H
Authorized Official - Last Name:WHARTON-ALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-399-3404
Mailing Address - Street 1:PO BOX 364479
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89036-8479
Mailing Address - Country:US
Mailing Address - Phone:702-399-3404
Mailing Address - Fax:702-399-1819
Practice Address - Street 1:1703 CIVIC CENTER DR #1B
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7273
Practice Address - Country:US
Practice Address - Phone:702-399-3404
Practice Address - Fax:702-399-1819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3863261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002260Medicaid
C96696Medicare UPIN
NV002002260Medicaid