Provider Demographics
NPI:1215655568
Name:ACEVIZ, OMAR
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:ACEVIZ
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 1:507 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-3466
Mailing Address - Country:US
Mailing Address - Phone:309-721-6294
Mailing Address - Fax:
Practice Address - Street 1:1520 W 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-2459
Practice Address - Country:US
Practice Address - Phone:563-421-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA143754163W00000X
IAA174108363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse