Healthcare Provider Details

I. General information

NPI: 1396923579
Provider Name (Legal Business Name): JENNIFER COBANOV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2008
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 TENNESSEE ST STE K1
REDLANDS CA
92373-8152
US

IV. Provider business mailing address

PO BOX 902
LOMA LINDA CA
92354-0902
US

V. Phone/Fax

Practice location:
  • Phone: 909-531-4427
  • Fax: 909-288-4731
Mailing address:
  • Phone: 909-647-8783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA108683
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: