Healthcare Provider Details

I. General information

NPI: 1689848541
Provider Name (Legal Business Name): IGNACIO OMENGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

461 N MULFORD RD SUITE #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 Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number036101370
License Number StateIL

VIII. Authorized Official

Name: IGNACIO UY OMENGAN
Title or Position: DOCTOR/OWNER
Credential: M.D., F.A.A.P.
Phone: 815-394-1930