Provider Demographics
NPI:1669634820
Name:OBERMYER, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:OBERMYER
Suffix:
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 1:21700 INTERTECH DR
Mailing Address - Street 2:SPRINGDALE HEALTH CENTER
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5197
Mailing Address - Country:US
Mailing Address - Phone:262-532-8300
Mailing Address - Fax:262-532-8600
Practice Address - Street 1:21700 INTERTECH DR
Practice Address - Street 2:SPRINGDALE HEALTH CENTER
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5197
Practice Address - Country:US
Practice Address - Phone:262-532-8300
Practice Address - Fax:262-532-8600
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118405207R00000X, 208000000X
WI51868207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1669634820Medicaid
WI1669634820Medicaid
WI736011304Medicare PIN