1912516790 NPI number — DR. OMAR CHOUDHURY M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912516790 NPI number — DR. OMAR CHOUDHURY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHOUDHURY
Provider First Name:
OMAR
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912516790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
10/20/2021
NPI Reactivation Date:
12/22/2021

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2799 W GRAND BLVD HENRY FORD HOSPITAL
Provider Second Line Business Mailing Address:
DEPARTMENT OF NEUROLOGY, K-11
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-282-7357
Provider Business Mailing Address Fax Number:
313-916-3014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2799 W GRAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48202-2608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-916-2585
Provider Business Practice Location Address Fax Number:
313-916-3014
Provider Enumeration Date:
07/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  79401 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 4301512388 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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