Provider Demographics
NPI:1649803719
Name:DR O MD LLC
Entity type:Organization
Organization Name:DR O MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOMINIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-770-3967
Mailing Address - Street 1:7828 S HOYNE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-5741
Mailing Address - Country:US
Mailing Address - Phone:480-770-3967
Mailing Address - Fax:
Practice Address - Street 1:7828 S HOYNE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-5741
Practice Address - Country:US
Practice Address - Phone:480-770-3967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty