Healthcare Provider Details

I. General information

NPI: 1659374601
Provider Name (Legal Business Name): WENDY TIPTON OBERDICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WENDY NANETTE TIPTON MD

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date: 05/23/2005
Reactivation Date: 05/24/2005

III. Provider practice location address

105 W STONE DR STE 1F
KINGSPORT TN
37660-3365
US

IV. Provider business mailing address

PO BOX 9
KINGSPORT TN
37662-0009
US

V. Phone/Fax

Practice location:
  • Phone: 423-230-2420
  • Fax: 423-230-2422
Mailing address:
  • Phone: 423-857-2066
  • Fax: 423-857-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200133
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD200133
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD46567
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: