Provider Demographics
NPI:1326611427
Name:OBEIDAT, ISLAM (MD)
Entity type:Individual
Prefix:
First Name:ISLAM
Middle Name:
Last Name:OBEIDAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CENTRAL AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4934
Mailing Address - Country:US
Mailing Address - Phone:505-724-6145
Mailing Address - Fax:505-724-6125
Practice Address - Street 1:G3230 BEECHER RD STE 2
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3604
Practice Address - Country:US
Practice Address - Phone:810-342-5800
Practice Address - Fax:810-342-5810
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2024-0172207R00000X
MI4351047844390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program