Provider Demographics
NPI:1659374601
Name:OBERDICK, WENDY TIPTON (MD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:TIPTON
Last Name:OBERDICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:WENDY
Other - Middle Name:NANETTE
Other - Last Name:TIPTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:STE 1F
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3365
Practice Address - Country:US
Practice Address - Phone:423-230-2420
Practice Address - Fax:423-230-2422
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2011-10-20
Deactivation Date:2005-05-23
Deactivation Code:
Reactivation Date:2005-05-24
Provider Licenses
StateLicense IDTaxonomies
LA200133207Q00000X
LAMD200133207Q00000X
TNMD46567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1623512Medicaid
TN1520114Medicaid
LA4J660Medicare PIN
G65207Medicare UPIN
TN1520114Medicaid
LA4J6606629Medicare PIN