Provider Demographics
NPI:1760741938
Name:OTHMAN, DAVID ZACHARY (MD, MHSA)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ZACHARY
Last Name:OTHMAN
Suffix:
Gender:M
Credentials:MD, MHSA
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:ZACHARY
Other - Last Name:OTHMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, MHSA
Mailing Address - Street 1:2202 N. HALSTED ST, SUITE 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:312-600-5826
Mailing Address - Fax:608-713-8272
Practice Address - Street 1:2202 N HALSTED ST STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3625
Practice Address - Country:US
Practice Address - Phone:312-600-5826
Practice Address - Fax:872-260-5008
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-09
Last Update Date:2023-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036144735207NP0225X, 207NS0135X, 207N00000X, 207ND0101X, 207NS0135X
CA143497207NS0135X, 207N00000X, 207ND0101X, 207NS0135X
FLME135549207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024369500Medicaid