Provider Demographics
NPI:1275710014
Name:OBERMARK OPTOMETRY, INC
Entity Type:Organization
Organization Name:OBERMARK OPTOMETRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER / MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:OBERMARK
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, ABOC
Authorized Official - Phone:636-239-7144
Mailing Address - Street 1:222 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-2154
Mailing Address - Country:US
Mailing Address - Phone:636-239-7144
Mailing Address - Fax:636-239-6266
Practice Address - Street 1:222 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2154
Practice Address - Country:US
Practice Address - Phone:636-239-7144
Practice Address - Fax:636-239-6266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO317927903Medicaid
MO4195 X 1285OtherHEALTHCARE USA
MO317927903Medicaid
MO4195 X 1285OtherHEALTHCARE USA
MO0985240001Medicare NSC
MOU51729Medicare UPIN