Healthcare Provider Details

I. General information

NPI: 1902591159
Provider Name (Legal Business Name): JAVIER OBESO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 10/03/2024
Certification Date: 04/05/2023
Deactivation Date: 11/09/2023
Reactivation Date: 11/27/2023

III. Provider practice location address

1432 BROADRICK DRIVE
DALTON GA
30720
US

IV. Provider business mailing address

1200 MEMORIAL DRIVE
DALTON GA
30720
US

V. Phone/Fax

Practice location:
  • Phone: 706-226-8990
  • Fax: 706-529-5317
Mailing address:
  • Phone: 706-226-8996
  • Fax: 706-272-6761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number15059
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: