MEDICARE: DR. JERRY C BOBO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	G084025	CA

General Provider Information

NPI Number	:	1194836429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY C BOBO M.D.

Provider Business Mailing Address
First Line	:	474 W VERMONT AVE STE 104
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92025-6584
Country	:	US
Telephone Number	:	760-432-9884
Fax Number	:	760-432-9953

Provider Business Practice Location Address
First Line	:	474 W VERMONT AVE STE 104
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92025-6584
Country	:	US
Telephone Number	:	760-432-9884
Fax Number	:	760-432-9953

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	02/29/2012

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