Healthcare Provider Details

I. General information

NPI: 1912911785
Provider Name (Legal Business Name): IGNACIO U OMENGAN MD FAAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 N MULFORD RD #10
ROCKFORD IL
61107
US

IV. Provider business mailing address

461 N MULFORD RD #10
ROCKFORD IL
61107-5190
US

V. Phone/Fax

Practice location:
  • Phone: 815-394-1930
  • Fax: 815-395-1064
Mailing address:
  • Phone: 815-394-1930
  • Fax: 815-395-1064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036101370
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: