Basic Information
| Provider Information | |||||||||
| NPI: | 1639176613 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OMER | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | WILLIAMS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | KATHERINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1520 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970588003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412967668 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1620 E 12TH ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412969151 | ||||||||
| FaxNumber: | 5412969156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 11/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 36687 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD157435 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1639176613 | 05 | OR | MEDICAID | 218112 | 05 | OR | MEDICAID | 64037328 | 05 | KY | MEDICAID |