Provider Demographics
NPI:1083716492
Name:OBERG, JEFFREY ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:OBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37500 HARVEST AVE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-2804
Mailing Address - Country:US
Mailing Address - Phone:440-934-2710
Mailing Address - Fax:440-934-2714
Practice Address - Street 1:37500 HARVEST AVE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-2804
Practice Address - Country:US
Practice Address - Phone:440-934-2710
Practice Address - Fax:440-934-2714
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5136152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOB4087591Medicare ID - Type Unspecified#41 OPTOMETRY
OHU91141Medicare UPIN