Provider Demographics
NPI:1639176613
Name:OMER, KATHERINE WILLIAMS (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:WILLIAMS
Last Name:OMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHERINE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-8003
Mailing Address - Country:US
Mailing Address - Phone:541-296-7668
Mailing Address - Fax:
Practice Address - Street 1:1620 E 12TH ST
Practice Address - Street 2:STE 200
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3213
Practice Address - Country:US
Practice Address - Phone:541-296-9151
Practice Address - Fax:541-296-9156
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36687208000000X
ORMD157435208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1639176613Medicaid
OR218112Medicaid
KY64037328Medicaid
ORR164669Medicare PIN
KY0691803Medicare PIN
OR383996Medicare PIN
OR1639176613Medicaid