Provider Demographics
NPI:1568209435
Name:ELWISHAHI, OMAR (MD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:ELWISHAHI
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 1:1050 AVE LAS PALMAS APT 411
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-5204
Mailing Address - Country:US
Mailing Address - Phone:925-964-7710
Mailing Address - Fax:
Practice Address - Street 1:1395 CALLE SAN RAFAEL
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-2518
Practice Address - Country:US
Practice Address - Phone:787-999-7620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17110-I390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program