Basic Information
| Provider Information | |||||||||
| NPI: | 1710060066 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOBBA | ||||||||
| FirstName: | JYOTHIRMAI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5943 STADIUM DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490093016 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5973 BEATRICE DR | ||||||||
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| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490099583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692867110 | ||||||||
| FaxNumber: | 2692867111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301079796 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 4301079796 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.