Provider Demographics
NPI:1568410603
Name:OBENSHAIN, WALLACE (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:OBENSHAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21922-0190
Mailing Address - Country:US
Mailing Address - Phone:410-398-4679
Mailing Address - Fax:410-620-3686
Practice Address - Street 1:251 S BOHEMIA AVE
Practice Address - Street 2:
Practice Address - City:CECILTON
Practice Address - State:MD
Practice Address - Zip Code:21913-0670
Practice Address - Country:US
Practice Address - Phone:410-275-8157
Practice Address - Fax:410-275-9919
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0035779207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD168491400Medicaid
MD080176795OtherMEDICARE RAILROAD
MD080176795OtherMEDICARE RAILROAD
MD595RMedicare PIN
MD595RMedicare ID - Type Unspecified