Healthcare Provider Details

I. General information

NPI: 1215937636
Provider Name (Legal Business Name): EYAS O OTHMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 W 156TH ST SUITE 107
HARVEY IL
60426-4260
US

IV. Provider business mailing address

PO BOX 1119
MATTESON IL
60443-4119
US

V. Phone/Fax

Practice location:
  • Phone: 708-333-0730
  • Fax:
Mailing address:
  • Phone: 708-747-5850
  • Fax: 708-747-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036108069
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: