Provider Demographics
NPI:1205007614
Name:DR. DANIEL R. OBERMARK OPTOMETRY PC
Entity Type:Organization
Organization Name:DR. DANIEL R. OBERMARK OPTOMETRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:OBERMARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-471-1080
Mailing Address - Street 1:P.O. BOX 709
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-0709
Mailing Address - Country:US
Mailing Address - Phone:573-471-1080
Mailing Address - Fax:573-471-1810
Practice Address - Street 1:1909 N. WESTWOOD BLVD.
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2807
Practice Address - Country:US
Practice Address - Phone:573-785-6717
Practice Address - Fax:573-785-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2935152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO318104809Medicaid
MO000015707Medicare PIN
MO318104809Medicaid
MODP3979Medicare PIN
MOU26376Medicare UPIN