Provider Demographics
NPI:1285894501
Name:OMAR, AYMAN I (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:AYMAN
Middle Name:I
Last Name:OMAR
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:SUITE 3100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-8417
Practice Address - Fax:217-545-8039
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130376712084N0400X
WI70514-202084N0400X
IL036-1206882084N0400X
GA848802084N0400X
IN01062696A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120688Medicaid
IL256510051Medicare PIN