Basic Information
Provider Information | |||||||||
NPI: | 1043217938 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OBERKROM | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 512 W MAIN ST | ||||||||
Address2: | P O BOX 158 | ||||||||
City: | COLE CAMP | ||||||||
State: | MO | ||||||||
PostalCode: | 653250158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6606680851 | ||||||||
FaxNumber: | 6606683041 | ||||||||
Practice Location | |||||||||
Address1: | 3700 W 10TH ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | SEDALIA | ||||||||
State: | MO | ||||||||
PostalCode: | 653012540 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608270015 | ||||||||
FaxNumber: | 6608277425 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 11/30/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 100576 | MO | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 203394127 | 05 | MO |   | MEDICAID | 23141020 | 01 | MP | BLUE CROSS BLUE SHIELD | OTHER |