Healthcare Provider Details

I. General information

NPI: 1417442369
Provider Name (Legal Business Name): OMAR YACOB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2018
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 UNITED DR STE 220
CONWAY AR
72032-7835
US

IV. Provider business mailing address

11001 EXECUTIVE CENTER DR STE 200
LITTLE ROCK AR
72211-4393
US

V. Phone/Fax

Practice location:
  • Phone: 501-358-6361
  • Fax: 501-358-6714
Mailing address:
  • Phone: 501-358-6361
  • Fax: 501-358-6714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-19041
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberE-19041
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: