Healthcare Provider Details

I. General information

NPI: 1750398251
Provider Name (Legal Business Name): JACK OBADIA D. O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 E CAMELBACK RD # 150
PHOENIX AZ
85016-4312
US

IV. Provider business mailing address

2725 E CAMELBACK RD # 150
PHOENIX AZ
85016-4312
US

V. Phone/Fax

Practice location:
  • Phone: 602-234-1700
  • Fax: 602-234-1900
Mailing address:
  • Phone: 602-234-1700
  • Fax: 602-234-1900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number2692
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: