Provider Demographics
NPI:1124361746
Name:MAHASNEH, OMAR ALI MOHAMMAD (MD)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:ALI MOHAMMAD
Last Name:MAHASNEH
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 1:1 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6722
Mailing Address - Country:US
Mailing Address - Phone:618-463-7240
Mailing Address - Fax:618-463-7216
Practice Address - Street 1:1400 S COULTER ST
Practice Address - Street 2:TTUHSC INTERNAL MEDICINE DEPARTMENT
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1786
Practice Address - Country:US
Practice Address - Phone:806-354-5417
Practice Address - Fax:806-351-3787
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6537207R00000X
MO2016028028208M00000X
TX390200000X
IL036.141503208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program