Provider Demographics
NPI:1104808054
Name:HAJ OBEID, JACK IBRAHIM (M D)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:IBRAHIM
Last Name:HAJ OBEID
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5980
Mailing Address - Country:US
Mailing Address - Phone:386-586-2050
Mailing Address - Fax:
Practice Address - Street 1:17929 HUNTING BOW CIR STE 102
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558
Practice Address - Country:US
Practice Address - Phone:813-751-7855
Practice Address - Fax:813-475-5283
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87987207R00000X, 207RC0200X, 207RS0012X, 207RP1001X
TXK9076207RC0200X
OK29034207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267303700Medicaid
FLH33257Medicare UPIN
FL71064BMedicare ID - Type Unspecified