Provider Demographics
NPI:1265698229
Name:AWATH, OMAR AHMMED
Entity type:Individual
Prefix:MR
First Name:OMAR
Middle Name:AHMMED
Last Name:AWATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5441 DUPONT AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-3127
Mailing Address - Country:US
Mailing Address - Phone:612-685-8048
Mailing Address - Fax:
Practice Address - Street 1:5441 DUPONT AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-3127
Practice Address - Country:US
Practice Address - Phone:612-685-8048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
MN253Z00000X253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No253Z00000XAgenciesIn Home Supportive Care