Provider Demographics
NPI:1215923974
Name:FATTAL, OMAR (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name:FATTAL
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 W 25TH ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-3108
Mailing Address - Country:US
Mailing Address - Phone:216-363-2304
Mailing Address - Fax:216-363-2356
Practice Address - Street 1:1730 W 25TH ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3108
Practice Address - Country:US
Practice Address - Phone:216-363-2304
Practice Address - Fax:216-363-2356
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2009-11-09
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
OH350849342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000368726OtherANTHEM
OH2580167Medicaid
OHP00754378Medicare PIN
OH4165362Medicare PIN
OH000000368726OtherANTHEM
OH2580167Medicaid