Provider Demographics
NPI:1578549861
Name:HURLBURT, OMER C III (MD)
Entity Type:Individual
Prefix:
First Name:OMER
Middle Name:C
Last Name:HURLBURT
Suffix:III
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 1:3913 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-6674
Mailing Address - Country:US
Mailing Address - Phone:513-423-0141
Mailing Address - Fax:513-423-2677
Practice Address - Street 1:3913 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-6674
Practice Address - Country:US
Practice Address - Phone:513-423-0141
Practice Address - Fax:513-423-2677
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35066740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0990996Medicaid
OH080164057Medicare PIN
OHF59794Medicare UPIN
OH0990996Medicaid