Provider Demographics
NPI:1851118996
Name:GAIDAROV, OMAR
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:GAIDAROV
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 1:8 NEWPORT TER APT 1A
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-3383
Mailing Address - Country:US
Mailing Address - Phone:858-243-0826
Mailing Address - Fax:
Practice Address - Street 1:145 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1802
Practice Address - Country:US
Practice Address - Phone:617-636-6534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program