Healthcare Provider Details

I. General information

NPI: 1851307672
Provider Name (Legal Business Name): MADHURI BOBBA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CARSON AVE STE 103
LA JUNTA CO
81050-2700
US

IV. Provider business mailing address

1200 CARSON AVE STE 103
LA JUNTA CO
81050-2700
US

V. Phone/Fax

Practice location:
  • Phone: 719-383-5925
  • Fax: 719-383-5928
Mailing address:
  • Phone: 719-383-5925
  • Fax: 719-383-5928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDR44733
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier03171027
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 2
IdentifierBO678330
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerBLUE CROSS
# 3
IdentifierP00370636
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: