Provider Demographics
NPI:1720055585
Name:OBED, JEROME R (DO)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:R
Last Name:OBED
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SE 15TH ST
Mailing Address - Street 2:SUITE #108
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1952
Mailing Address - Country:US
Mailing Address - Phone:954-990-6591
Mailing Address - Fax:954-990-6524
Practice Address - Street 1:500 SE 15TH ST
Practice Address - Street 2:SUITE #108
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1952
Practice Address - Country:US
Practice Address - Phone:954-990-6591
Practice Address - Fax:954-990-6524
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9463207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS 9463OtherMEDICAL LICENSE
FL274900900Medicaid
FLOS 9463OtherMEDICAL LICENSE