Healthcare Provider Details

I. General information

NPI: 1255986576
Provider Name (Legal Business Name): OTHMAN REZKI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2019
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W POLK ST # 611
CHICAGO IL
60612-3723
US

IV. Provider business mailing address

4372 COMMERCIAL WAY
SPRING HILL FL
34606-1965
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number002120
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN27973
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: