Healthcare Provider Details

I. General information

NPI: 1912138660
Provider Name (Legal Business Name): OTHMAN MAHMOUD MOHAMMAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 S MATTIS AVE
CHAMPAIGN IL
61821-5923
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-2855
  • Fax: 217-365-2856
Mailing address:
  • Phone: 217-383-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036166927
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number066441
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number066441
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number261296
License Number StateMA
# 5
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036166927
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: