Healthcare Provider Details

I. General information

NPI: 1760681258
Provider Name (Legal Business Name): JOSIPA BUBALO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 12/14/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3324 CHANATE RD
SANTA ROSA CA
95404-1708
US

IV. Provider business mailing address

18396 MILL CT
SARATOGA CA
95070-3058
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-4070
  • Fax: 707-576-4087
Mailing address:
  • Phone: 707-206-1356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: