MEDICARE: DR. KENNETH J O'BARA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	MD00018701	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	171941	OTHER	WA	LABOR & INDUSTRIES

General Provider Information

NPI Number	:	1144361304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH J O'BARA M.D.

Provider Business Mailing Address
First Line	:	6720 FORT DENT WAY
Second Line	:	SUITE 110
City	:	TUKWILA
State	:	WA
Zip	:	98188-8508
Country	:	US
Telephone Number	:	206-242-3651
Fax Number	:	206-433-7946

Provider Business Practice Location Address
First Line	:	6720 FORT DENT WAY
Second Line	:	SUITE 110
City	:	TUKWILA
State	:	WA
Zip	:	98188-8508
Country	:	US
Telephone Number	:	206-242-3651
Fax Number	:	206-433-7946

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	07/08/2007

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