Healthcare Provider Details

I. General information

NPI: 1760741938
Provider Name (Legal Business Name): DAVID ZACHARY OTHMAN M.D., M.H.S.A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DAVID ZACHARY OTHMAN M.D., M.H.S.A

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 N HALSTED ST STE 1
CHICAGO IL
60614-3625
US

IV. Provider business mailing address

2202 N. HALSTED ST, SUITE 1
CHICAGO IL
60614
US

V. Phone/Fax

Practice location:
  • Phone: 312-600-5826
  • Fax: 872-260-5008
Mailing address:
  • Phone: 312-600-5826
  • Fax: 872-260-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036144735
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number143497
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036144735
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number143497
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number036144735
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number143497
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number036144735
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: