Provider Demographics
NPI:1720019375
Name:OBERMARK, EDWARD OMER (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:OMER
Last Name:OBERMARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:EDWARD
Other - Middle Name:OMER
Other - Last Name:OBERMARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:222 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-2123
Mailing Address - Country:US
Mailing Address - Phone:636-239-7144
Mailing Address - Fax:636-239-6266
Practice Address - Street 1:222 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2123
Practice Address - Country:US
Practice Address - Phone:636-239-7144
Practice Address - Fax:636-239-6266
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03188152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO317927903Medicaid
MO000008961Medicare ID - Type UnspecifiedPROVIDER LOCATOR ID
MO317927903Medicaid