Healthcare Provider Details

I. General information

NPI: 1871382267
Provider Name (Legal Business Name): OMAR IBRAHEEM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 DOVER LN
AURORA IL
60504-5996
US

IV. Provider business mailing address

1010 DOVER LN
AURORA IL
60504-5996
US

V. Phone/Fax

Practice location:
  • Phone: 208-293-2435
  • Fax:
Mailing address:
  • Phone: 208-293-2435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberI16564092280
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: