Provider Demographics
NPI:1215947221
Name:OBERG, LANCE G (M D)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:G
Last Name:OBERG
Suffix:
Gender:M
Credentials:M D
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 848476
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-8476
Mailing Address - Country:US
Mailing Address - Phone:254-202-4655
Mailing Address - Fax:254-202-4697
Practice Address - Street 1:7300 BOSQUE BLVD.
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710
Practice Address - Country:US
Practice Address - Phone:254-202-2600
Practice Address - Fax:254-202-2650
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE72122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00F72FOtherBLUE CROSS BLUE SHIELD
TX098299301Medicaid
TX00F72FOtherBLUE CROSS BLUE SHIELD