Provider Demographics
NPI:1780174557
Name:OBERG, PHILLIP (DO)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:OBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1187 E 3900 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1201
Mailing Address - Country:US
Mailing Address - Phone:435-673-1149
Mailing Address - Fax:435-673-1182
Practice Address - Street 1:368 E RIVERSIDE DR STE A
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6897
Practice Address - Country:US
Practice Address - Phone:435-673-1149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL1352207R00000X
NVDO2870208D00000X
UT6069280-1204207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty