Provider Demographics
NPI:1194709220
Name:OBERMARK, DANIEL ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ROBERT
Last Name:OBERMARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 709
Mailing Address - Street 2:1250 NORTH MAIN STREET
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-0709
Mailing Address - Country:US
Mailing Address - Phone:573-471-1080
Mailing Address - Fax:573-471-1810
Practice Address - Street 1:1250 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4827
Practice Address - Country:US
Practice Address - Phone:573-471-1080
Practice Address - Fax:573-471-1810
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2935152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO318104809Medicaid
MODP3979Medicare PIN
MOU26376Medicare UPIN
MO318104809Medicaid