Provider Demographics
NPI:1295375806
Name:METWALLY, OMAR AZZAM MOHAMED (MBBCH)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:AZZAM MOHAMED
Last Name:METWALLY
Suffix:
Gender:M
Credentials:MBBCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 SOUTH MARYLAND AVE
Mailing Address - Street 2:MC 2026
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637
Mailing Address - Country:US
Mailing Address - Phone:773-702-6024
Mailing Address - Fax:
Practice Address - Street 1:5841 SOUTH MARYLAND AVE
Practice Address - Street 2:MC 2026
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-702-6024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-11
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1509592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology