Provider Demographics
NPI:1952001513
Name:JASIM, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:JASIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9754 KENORA WOODS LN
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-2928
Mailing Address - Country:US
Mailing Address - Phone:619-905-8285
Mailing Address - Fax:
Practice Address - Street 1:1380 S 43RD ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-3408
Practice Address - Country:US
Practice Address - Phone:619-263-8116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87685183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty