Provider Demographics
NPI:1770787673
Name:ANSARI, MUHAMMAD OMER MUMTAZ (MD)
Entity type:Individual
Prefix:DR
First Name:MUHAMMAD OMER
Middle Name:MUMTAZ
Last Name:ANSARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:OMER
Other - Middle Name:
Other - Last Name:ANSARI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:396 REMINGTON BLVD STE 380
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4315
Mailing Address - Country:US
Mailing Address - Phone:224-273-4000
Mailing Address - Fax:224-273-4027
Practice Address - Street 1:396 REMINGTON BLVD STE 380
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4315
Practice Address - Country:US
Practice Address - Phone:242-273-4000
Practice Address - Fax:224-273-4027
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-126472207Q00000X
IN01068102A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RES000Medicare UPIN