Provider Demographics
NPI:1558488502
Name:O'BRIEN, EDWARD R (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:R
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 27TH AVE.
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-0000
Mailing Address - Country:US
Mailing Address - Phone:319-626-4228
Mailing Address - Fax:
Practice Address - Street 1:2700 27TH AVE.
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241
Practice Address - Country:US
Practice Address - Phone:319-626-4228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3261207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1558488502Medicare UPIN