Provider Demographics
NPI:1396779435
Name:MULLA-OSSMANN, OMAR (MD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:MULLA-OSSMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 CEREAL AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-2784
Mailing Address - Country:US
Mailing Address - Phone:513-867-2560
Mailing Address - Fax:513-737-3389
Practice Address - Street 1:1010 CEREAL AVE STE 212
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-2776
Practice Address - Country:US
Practice Address - Phone:513-867-2560
Practice Address - Fax:513-737-3389
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350844542084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200528730Medicaid
KY64110406Medicaid
P00681246OtherRR MEDICARE
OH2484315Medicaid
L10123Medicare UPIN
KY64110406Medicaid
OHP00203427Medicare PIN
OH2484315Medicaid