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General NPI Number Information
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NPI Number | 1467508812
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Entity Type | Individual
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Provider Name | JON RICHARD OBERLY O. D.
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Gender | Male
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Dates
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Enumeration Date | 01/26/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2500 MEADOWBROOK MALL JC PENNEY OPTICAL
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City | BRIDGEPORT
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State | WV
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Zip | 26330-9792
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Country | US
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Telephone | 304-842-8515
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Fax | 214-427-2588
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Provider Business Mailing Address
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Address Line | 965 STEWART ST
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City | MORGANTOWN
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State | WV
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Zip | 26505-1800
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Country | US
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Telephone | 304-599-8380
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 619OD
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License Number State | WV
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