Provider Demographics
NPI:1760461818
Name:OBESO, MARY BETH (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:OBESO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1100 LAKE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1015
Mailing Address - Country:US
Mailing Address - Phone:708-524-2131
Mailing Address - Fax:708-524-2142
Practice Address - Street 1:1100 LAKE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1015
Practice Address - Country:US
Practice Address - Phone:708-848-4188
Practice Address - Fax:708-524-2142
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036095647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01615849OtherBCBS
IL036095647Medicaid
ILG53616Medicare UPIN