Provider Demographics
NPI:1881081685
Name:WAQHAR, OMAR S (DO)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:S
Last Name:WAQHAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7422 S 50TH ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-7714
Mailing Address - Country:US
Mailing Address - Phone:928-785-7382
Mailing Address - Fax:734-402-8987
Practice Address - Street 1:1262 AZIZ DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-5094
Practice Address - Country:US
Practice Address - Phone:928-785-7382
Practice Address - Fax:734-402-8987
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2024-06-25
Deactivation Date:2023-08-15
Deactivation Code:
Reactivation Date:2023-08-25
Provider Licenses
StateLicense IDTaxonomies
IL036.1501722084P0800X
IN02007204A2084P0800X
WI713682084P0800X
MI51010218452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036150172Medicaid
WI100092981Medicaid