Provider Demographics
NPI:1154908937
Name:OWENS, OMARI (DPM)
Entity type:Individual
Prefix:
First Name:OMARI
Middle Name:
Last Name:OWENS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 SAINT JOHNS MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5298
Mailing Address - Country:US
Mailing Address - Phone:904-823-3301
Mailing Address - Fax:
Practice Address - Street 1:6 SAINT JOHNS MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5298
Practice Address - Country:US
Practice Address - Phone:904-823-3301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FLPO4602213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No174400000XOther Service ProvidersSpecialist