Provider Demographics
NPI:1689848541
Name:IGNACIO OMENGAN
Entity Type:Organization
Organization Name:IGNACIO OMENGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IGNACIO
Authorized Official - Middle Name:UY
Authorized Official - Last Name:OMENGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FAAP
Authorized Official - Phone:815-394-1930
Mailing Address - Street 1:461 N MULFORD RD
Mailing Address - Street 2:SUITE #10
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5190
Mailing Address - Country:US
Mailing Address - Phone:815-394-1930
Mailing Address - Fax:815-395-1064
Practice Address - Street 1:461 N MULFORD RD
Practice Address - Street 2:SUITE #10
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5190
Practice Address - Country:US
Practice Address - Phone:815-394-1930
Practice Address - Fax:815-395-1064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361013702080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH09889Medicare UPIN