Provider Demographics
NPI:1699818120
Name:OBADIAH, JOSEPH MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:OBADIAH
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:5330 NE GLISAN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3069
Practice Address - Country:US
Practice Address - Phone:503-215-9080
Practice Address - Fax:503-215-9099
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047161207N00000X
MO2003010752207N00000X
ORMD26968207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH94431OtherUPIN
ORP00973909OtherRR MEDICARE
OR028538Medicaid
ORH94431OtherUPIN