Basic Information
| Provider Information | |||||||||
| NPI: | 1316101264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABDURRAQEEB | ||||||||
| FirstName: | OBAYDAH | ||||||||
| MiddleName: | AHMAD | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1137 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329021137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219529696 | ||||||||
| FaxNumber: | 3219527937 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 SILVER PALM AVE | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217332021 | ||||||||
| FaxNumber: | 3217270884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2008 | ||||||||
| LastUpdateDate: | 08/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | DO2182 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS11259 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1524832 | 05 | TN | MEDICAID | 3373352 | 01 | TN | MEDICARE GRP UFP | OTHER | 3373352 | 01 | TN | MEDICAID GRP UFP | OTHER | OS11259 | 01 | FL | MEDICAL LICENSE | OTHER |