Basic Information
| Provider Information | |||||||||
| NPI: | 1558447847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOBERNE | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DOBERNE | ||||||||
| OtherFirstName: | LEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2204 GRANT RD | ||||||||
| Address2: | #103 | ||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940403855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509678841 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2204 GRANT RD | ||||||||
| Address2: | #103 | ||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940403855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509678841 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | G36173 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 00G361730 | 05 | CA | MEDICAID |