Healthcare Provider Details

I. General information

NPI: 1104808054
Provider Name (Legal Business Name): JACK IBRAHIM HAJ OBEID M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 USF MAGNOLIA DR
TAMPA FL
33612-9416
US

IV. Provider business mailing address

PO BOX 198441
ATLANTA GA
30384-8441
US

V. Phone/Fax

Practice location:
  • Phone: 813-745-7365
  • Fax: 813-449-8618
Mailing address:
  • Phone: 813-745-7365
  • Fax: 813-449-8618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberME87987
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: