Provider Demographics
NPI:1578067369
Name:QAQISH, OMAR SAMIH (MD)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:SAMIH
Last Name:QAQISH
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 1:49473 POINTE XING
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6433
Mailing Address - Country:US
Mailing Address - Phone:312-315-7753
Mailing Address - Fax:
Practice Address - Street 1:12000 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3570
Practice Address - Country:US
Practice Address - Phone:248-967-7795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301504324207R00000X
390200000X
MI2186120341207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine