Provider Demographics
NPI:1740644384
Name:OBERST, ERIC (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:OBERST
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 1:1200 NW 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2906
Mailing Address - Country:US
Mailing Address - Phone:503-413-7074
Mailing Address - Fax:
Practice Address - Street 1:913 N DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2503
Practice Address - Country:US
Practice Address - Phone:270-706-5275
Practice Address - Fax:270-706-1051
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-10
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP645207R00000X
ORPG178246390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program