Basic Information
| Provider Information | |||||||||
| NPI: | 1720540347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ATIQ | ||||||||
| FirstName: | OSMAN | ||||||||
| MiddleName: | OMAR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 E DATE PALM PASEO APT 2018 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917647625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707181994 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST DEPT OF | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2019 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/27/2022 | ||||||||
| NPIReactivationDate: | 08/04/2022 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | A179232 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 208M00000X | A179232 | CA | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | A179232 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | E-14140 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 233001795 | 05 | AR | MEDICAID |