Provider Demographics
NPI:1487320115
Name:ASSALY, OMAR RAGHEB
Entity type:Individual
Prefix:MR
First Name:OMAR
Middle Name:RAGHEB
Last Name:ASSALY
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 1:6710 VICTORIA CT
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-3293
Mailing Address - Country:US
Mailing Address - Phone:567-249-9437
Mailing Address - Fax:
Practice Address - Street 1:3640 COLONEL GLENN HWY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45435-0002
Practice Address - Country:US
Practice Address - Phone:937-775-3458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-22
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program