Provider Demographics
NPI:1588684542
Name:OOMMEN, MATHEW (MD SC)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:
Last Name:OOMMEN
Suffix:
Gender:M
Credentials:MD SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6449 S PULASKI RD
Mailing Address - Street 2:STE# 110
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-5148
Mailing Address - Country:US
Mailing Address - Phone:773-585-0001
Mailing Address - Fax:630-920-0395
Practice Address - Street 1:6449 S PULASKI RD
Practice Address - Street 2:STE# 110
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5148
Practice Address - Country:US
Practice Address - Phone:773-585-0001
Practice Address - Fax:630-920-0395
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21607634OtherBCBS
ILC41720Medicare UPIN
IL467820Medicare ID - Type Unspecified