Provider Demographics
NPI:1972166700
Name:AL AZZAWI, OMAR
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:AL AZZAWI
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 1:276 COLONNADE DR APT 32
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-4964
Mailing Address - Country:US
Mailing Address - Phone:434-218-8404
Mailing Address - Fax:434-202-1267
Practice Address - Street 1:276 COLONNADE DR APT 32
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4964
Practice Address - Country:US
Practice Address - Phone:434-218-8404
Practice Address - Fax:434-202-1267
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA318814-906132343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)