Provider Demographics
NPI:1083903645
Name:AL-HEETI, OMAR MOHAMMAD (MD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:MOHAMMAD
Last Name:AL-HEETI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 W HAY ST STE 212
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-6376
Mailing Address - Country:US
Mailing Address - Phone:217-876-4390
Mailing Address - Fax:217-876-4395
Practice Address - Street 1:304 W HAY ST STE 212
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6376
Practice Address - Country:US
Practice Address - Phone:217-876-4390
Practice Address - Fax:217-876-4395
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036133842207R00000X
IL036.133842207RI0200X, 207RI0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036133842OtherMD LICENSE