Healthcare Provider Details

I. General information

NPI: 1699818120
Provider Name (Legal Business Name): JOSEPH MICHAEL OBADIAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5330 NE GLISAN ST SUITE 200
PORTLAND OR
97213-3069
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-9080
  • Fax: 503-215-9099
Mailing address:
  • Phone: 503-215-6494
  • Fax: 503-215-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD00047161
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2003010752
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD26968
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: