Basic Information
Provider Information
NPI: 1003802869
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DURRA
FirstName: OMAR
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3530 WILSHIRE BLVD
Address2: #350
City: LOS ANGELES
State: CA
PostalCode: 900102328
CountryCode: US
TelephoneNumber: 2136373703
FaxNumber: 2136390797
Practice Location
Address1: 8700 BEVERLY BLVD
Address2: SUITE 8211
City: WEST HOLLYWOOD
State: CA
PostalCode: 900481804
CountryCode: US
TelephoneNumber: 2136373703
FaxNumber: 2136390797
Other Information
ProviderEnumerationDate: 09/26/2005
LastUpdateDate: 08/30/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207L00000XA78304CAY Allopathic & Osteopathic PhysiciansAnesthesiology 

No ID Information.


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