Basic Information
| Provider Information | |||||||||
| NPI: | 1467422097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KHADRA M OSMAN M D P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1625 SE 3RD AVE | ||||||||
| Address2: | 400 | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548320055 | ||||||||
| FaxNumber: | 9548320262 | ||||||||
| Practice Location | |||||||||
| Address1: | 1625 SE 3RD AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548320055 | ||||||||
| FaxNumber: | 9548320262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 08/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | OSMAN | ||||||||
| AuthorizedOfficialFirstName: | KHADRA | ||||||||
| AuthorizedOfficialMiddleName: | MOHAMOUD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9548320055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | ME0060084 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 370049600 | 05 | FL | MEDICAID |