Provider Demographics
NPI:1619145794
Name:OBERMARK OPTOMETRY, INC.
Entity Type:Organization
Organization Name:OBERMARK OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:OBERMARK
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, ABOC
Authorized Official - Phone:636-239-7144
Mailing Address - Street 1:PO BOX 756
Mailing Address - Street 2:113 SOUTH ALVARADO STREET
Mailing Address - City:BELLE
Mailing Address - State:MO
Mailing Address - Zip Code:65013-0756
Mailing Address - Country:US
Mailing Address - Phone:573-859-6614
Mailing Address - Fax:573-859-6742
Practice Address - Street 1:113 SOUTH ALVARADO ST
Practice Address - Street 2:
Practice Address - City:BELLE
Practice Address - State:MO
Practice Address - Zip Code:65013-0756
Practice Address - Country:US
Practice Address - Phone:573-859-6614
Practice Address - Fax:573-859-6742
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OBERMARK OPTOMETRY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03188152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO317927903Medicaid
MO4195 X 1285OtherHEALTHCARE USA
MO317927903Medicaid
MO========= OBEOtherMERCY HEALTH PLANS
MO4195 X 1285OtherHEALTHCARE USA
MOU51729Medicare PIN