Omar Mudallal

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

036147331 Issued in IL

Practice address

915 N Grand Blvd
Saint Louis, MO 63106-1621

Phone

(314) 652-4100

NPI assigned

Sep 30, 2012

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1348963200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1712016000000",
    "number": "1023369097",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "915 N GRAND BLVD",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631061621",
            "telephone_number": "314-652-4100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "915 N GRAND BLVD",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631061621",
            "telephone_number": "314-652-4100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MUDALLAL",
        "first_name": "OMAR",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-09-30",
        "last_updated": "2024-04-02",
        "certification_date": "2024-04-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "IL",
            "license": "036147331",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• MTR, LLC
• Roeshelle Renne Mu'Min, LCSW
• Lamya Suhail Mubayed, MD
• Amy Muchnick
• Marilyn Muckerman, MSW,LCSW
• Mohamed Fawzi Mudarres
• Carrie Ann Mudd, M.D.
• Christopher David Mudd, M.D.
• Gregory D Mudd
• Kialy Ann Mudd, FNP-C

• Internal Medicine Physician in Saint Louis, MO
• Providers in Saint Louis, MO by specialty
• Internal Medicine Physician in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 2, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.