Basic Information
| Provider Information | |||||||||
| NPI: | 1104077312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OMAR | ||||||||
| FirstName: | KHAWAJA | ||||||||
| MiddleName: | OWAIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 MACCORKLE AVE SE STE 700 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047207305 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3100 MACCORKLE AVE SE STE 700 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047207305 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2008 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 2014027663 | MO | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 01069485A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 30789 | WV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201022120 | 05 | IN | MEDICAID |