Healthcare Provider Details

I. General information

NPI: 1699267310
Provider Name (Legal Business Name): RACHEL SOSSAMAN OBROCK OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7747 W JEFFERSON BLVD STE A
FORT WAYNE IN
46804
US

IV. Provider business mailing address

PO BOX 549
WABASH IN
46992-0549
US

V. Phone/Fax

Practice location:
  • Phone: 260-459-8400
  • Fax: 260-459-8401
Mailing address:
  • Phone: 260-569-9550
  • Fax: 260-569-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004086
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: