Provider Demographics
NPI:1528159316
Name:OBERMILLER, LEO EUGENE JR (MD)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:EUGENE
Last Name:OBERMILLER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W 8TH AVE
Mailing Address - Street 2:MOTHER GAMELIN BLDG, 3RD FLOOR, ROOM 207305
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2307
Mailing Address - Country:US
Mailing Address - Phone:509-474-6842
Mailing Address - Fax:509-474-6606
Practice Address - Street 1:105 W 8TH AVE STE 1000
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2327
Practice Address - Country:US
Practice Address - Phone:509-474-4500
Practice Address - Fax:509-474-4487
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025209207RN0300X
IDM5092207RN0300X
WAMD00019462207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010000219OtherREGENCE BLUE SHIELD OF ID
ID805903500Medicaid
WA8111304Medicaid
WA8111304Medicaid
AB12474Medicare PIN
A07885Medicare UPIN
390008496Medicare PIN