Provider Demographics
NPI:1326063116
Name:OBETZ, DOUGLAS LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:LEE
Last Name:OBETZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15100 WASHINGTON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HAYMARKET
Mailing Address - State:VA
Mailing Address - Zip Code:20169-4918
Mailing Address - Country:US
Mailing Address - Phone:703-753-0122
Mailing Address - Fax:703-753-0171
Practice Address - Street 1:15100 WASHINGTON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-4918
Practice Address - Country:US
Practice Address - Phone:703-753-0122
Practice Address - Fax:703-753-0171
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000980111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU43649Medicare UPIN
TN252928Medicare ID - Type Unspecified