Basic Information
| Provider Information | |||||||||
| NPI: | 1023369097 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MUDALLAL | ||||||||
| FirstName: | OMAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 MAPLE SUMMIT RD | ||||||||
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| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620522028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184986402 | ||||||||
| FaxNumber: | 6184988439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2012 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 036147331 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.