Provider Demographics
NPI:1578790481
Name:OBMACES, BERNADETTE A (MD)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:A
Last Name:OBMACES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 ST MARY DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-7502
Mailing Address - Country:US
Mailing Address - Phone:219-286-3765
Mailing Address - Fax:
Practice Address - Street 1:3800 ST MARY DR
Practice Address - Street 2:SUITE 204
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-7502
Practice Address - Country:US
Practice Address - Phone:219-286-3765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072158A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20113882Medicaid
INM714850008Medicare PIN