Provider Demographics
NPI:1871869438
Name:IBRAHIM, OMER
Entity type:Individual
Prefix:
First Name:OMER
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 N STATE ST STE 900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-9104
Mailing Address - Country:US
Mailing Address - Phone:312-245-9965
Mailing Address - Fax:312-245-9964
Practice Address - Street 1:515 N STATE ST STE 900
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654
Practice Address - Country:US
Practice Address - Phone:312-245-9965
Practice Address - Fax:312-245-9964
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.143080207NS0135X
IL036143080207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty