Healthcare Provider Details

I. General information

NPI: 1720019375
Provider Name (Legal Business Name): EDWARD OMER OBERMARK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: EDWARD OMER OBERMARK O.D.

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W MAIN ST
WASHINGTON MO
63090-2123
US

IV. Provider business mailing address

222 W MAIN ST
WASHINGTON MO
63090-2123
US

V. Phone/Fax

Practice location:
  • Phone: 636-239-7144
  • Fax: 636-239-6266
Mailing address:
  • Phone: 636-239-7144
  • Fax: 636-239-6266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03188
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: