Healthcare Provider Details

I. General information

NPI: 1871715771
Provider Name (Legal Business Name): JACEK ZDZISLAW OBARA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 ROBINSON ST STE 100 COMMUNITY HEALTH AND DENTAL CARE
POTTSTOWN PA
19464-6421
US

IV. Provider business mailing address

11 ROBINSON ST SUITE 100
POTTSTOWN PA
19464-6421
US

V. Phone/Fax

Practice location:
  • Phone: 610-326-9460
  • Fax:
Mailing address:
  • Phone: 610-326-9460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number235325
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD443274
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: