Healthcare Provider Details

I. General information

NPI: 1528034212
Provider Name (Legal Business Name): ELIJAH MOBLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 10/02/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15366 11TH ST STE Q
VICTORVILLE CA
92395-3726
US

IV. Provider business mailing address

20258 US HIGHWAY 18 PMB 514 STE 430
APPLE VALLEY CA
92307-6197
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-6201
  • Fax: 760-241-6203
Mailing address:
  • Phone: 760-946-0100
  • Fax: 760-946-3176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number5725
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberCA286A
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: