Provider Demographics
NPI:1114488467
Name:OMAR, MAZEN BASSAM (MD)
Entity Type:Individual
Prefix:
First Name:MAZEN
Middle Name:BASSAM
Last Name:OMAR
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 1:1431 OPUS PL STE 110
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1164
Mailing Address - Country:US
Mailing Address - Phone:888-279-0002
Mailing Address - Fax:833-638-0302
Practice Address - Street 1:1431 OPUS PL STE 110
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1164
Practice Address - Country:US
Practice Address - Phone:888-279-0002
Practice Address - Fax:833-638-0302
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3174972084P0800X
ALMD.419482084P0800X
IL036.1659072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry