Basic Information
| Provider Information | |||||||||
| NPI: | 1871529024 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TOLOSA | ||||||||
| FirstName: | BOBBY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR BLDG B | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 N SAWYER RD | ||||||||
| Address2: | |||||||||
| City: | KENDALLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467552572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603478030 | ||||||||
| FaxNumber: | 2603478035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 32336 | IA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 20152 | NE | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 01078773A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 10025323300 | 05 | NE | MEDICAID | 2169730 | 05 | IA | MEDICAID |