Provider Demographics
NPI:1750398251
Name:OBADIA, JACK (D O)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:OBADIA
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 E CAMELBACK RD
Mailing Address - Street 2:# 150
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4312
Mailing Address - Country:US
Mailing Address - Phone:602-234-1700
Mailing Address - Fax:602-234-1900
Practice Address - Street 1:2725 E CAMELBACK RD
Practice Address - Street 2:# 150
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4312
Practice Address - Country:US
Practice Address - Phone:602-234-1700
Practice Address - Fax:602-234-1900
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2692207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AS4290687Medicare ID - Type Unspecified
AZF41775Medicare UPIN