Healthcare Provider Details

I. General information

NPI: 1386865244
Provider Name (Legal Business Name): OMAR S KHOKHAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: OMAR S KHOKHAR MD

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

IV. Provider business mailing address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3000
  • Fax: 309-664-3026
Mailing address:
  • Phone: 309-664-3000
  • Fax: 309-664-3026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36117349
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number36117349
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: