Healthcare Provider Details

I. General information

NPI: 1255452124
Provider Name (Legal Business Name): WAEL MOHAMMAD OTAIBI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 E LAKE SHORE DR STE 105
DECATUR IL
62521-3800
US

IV. Provider business mailing address

3051 HOLLIS DR FL 2
SPRINGFIELD IL
62704-7452
US

V. Phone/Fax

Practice location:
  • Phone: 217-329-1000
  • Fax: 217-329-1055
Mailing address:
  • Phone: 217-523-5432
  • Fax: 217-492-9643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number254927
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5101015634
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34.011232
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036150787
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: