Basic Information
| Provider Information | |||||||||
| NPI: | 1770077083 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OMAR | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | BRANDON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD/MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 653-1 WEST 8TH STREET | ||||||||
| Address2: | |||||||||
| City: | JCAKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043831003 | ||||||||
| FaxNumber: | 9042447388 | ||||||||
| Practice Location | |||||||||
| Address1: | 653-1 WEST 8TH STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043831003 | ||||||||
| FaxNumber: | 9042447388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2018 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TRN27652 | FL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | TRN27652 | 01 | FL | FLORIDA TRAINING LICENSE | OTHER |