Provider Demographics
NPI:1962474742
Name:OMIDVARI, KARAN (MD)
Entity type:Individual
Prefix:DR
First Name:KARAN
Middle Name:
Last Name:OMIDVARI
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 1:170 E 87TH ST APT W11A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-2238
Mailing Address - Country:US
Mailing Address - Phone:201-967-8425
Mailing Address - Fax:201-263-4665
Practice Address - Street 1:385 PROSPECT AVE STE 204
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2570
Practice Address - Country:US
Practice Address - Phone:551-996-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219979207R00000X, 207RP1001X, 208M00000X
NJMA56381208M00000X
NJ139772207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ80187Medicaid
NJ25MA05638100OtherSTATE LICENSE
NJ80187Medicaid