Provider Demographics
NPI:1902261365
Name:OMAR, JIBRIL
Entity Type:Individual
Prefix:
First Name:JIBRIL
Middle Name:
Last Name:OMAR
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 1:912 E 24TH ST
Mailing Address - Street 2:SUITE M112
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3869
Mailing Address - Country:US
Mailing Address - Phone:952-217-0730
Mailing Address - Fax:612-246-3055
Practice Address - Street 1:912 E 24TH ST
Practice Address - Street 2:SUITE M112
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3869
Practice Address - Country:US
Practice Address - Phone:952-217-0730
Practice Address - Fax:612-246-3055
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver