Healthcare Provider Details

I. General information

NPI: 1528159316
Provider Name (Legal Business Name): LEO EUGENE OBERMILLER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W 8TH AVE STE 1000
SPOKANE WA
99204-2327
US

IV. Provider business mailing address

101 W 8TH AVE MOTHER GAMELIN BLDG, 3RD FLOOR, ROOM 207305
SPOKANE WA
99204-2307
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-4500
  • Fax: 509-474-4487
Mailing address:
  • Phone: 509-474-6842
  • Fax: 509-474-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number025209
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberM5092
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD00019462
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: