Basic Information
Provider Information | |||||||||
NPI: | 1255358743 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHEEMA | ||||||||
FirstName: | OMAR | ||||||||
MiddleName: | MUKHTAR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2900 W OKLAHOMA AVE FL 4 | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532154330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4146462438 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2900 W OKLAHOMA AVE FL 4 | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532154330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4146462438 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M8591 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RA0001X | 59941 | WI | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 197983301 | 05 | TX |   | MEDICAID | J40893 | 01 | MA | BLUE SHIELD | OTHER | 197983304 | 05 | TX |   | MEDICAID | 197983303 | 05 | TX |   | MEDICAID | 2131048 | 05 | MA |   | MEDICAID | 8AH675 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |