Provider Demographics
NPI:1992986053
Name:ODESSA MEDICAL ENTERPRISES PLLC
Entity type:Organization
Organization Name:ODESSA MEDICAL ENTERPRISES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHAVAR
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-332-5557
Mailing Address - Street 1:PO BOX 7179
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-7179
Mailing Address - Country:US
Mailing Address - Phone:432-332-5557
Mailing Address - Fax:432-332-5558
Practice Address - Street 1:500 N WASHINGTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4428
Practice Address - Country:US
Practice Address - Phone:432-332-5557
Practice Address - Fax:432-332-5558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9047207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00Z125Medicare Oscar/Certification
G39470Medicare UPIN