Provider Demographics
NPI:1336197367
Name:DALLOUL, OMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name:DALLOUL
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 1:1860 W WINCHESTER RD
Mailing Address - Street 2:STE 107
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5312
Mailing Address - Country:US
Mailing Address - Phone:847-247-1010
Mailing Address - Fax:847-247-1011
Practice Address - Street 1:1860 W WINCHESTER RD
Practice Address - Street 2:STE 107
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5312
Practice Address - Country:US
Practice Address - Phone:847-247-1010
Practice Address - Fax:847-247-1011
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088845207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF93176Medicare UPIN
IL489220Medicare ID - Type Unspecified