Healthcare Provider Details

I. General information

NPI: 1720108012
Provider Name (Legal Business Name): JORG A BOBER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 KINGSLEY AVE SUITE 9-G
ORANGE PARK FL
32073-4537
US

IV. Provider business mailing address

PO BOX 1653
ORANGE PARK FL
32067-1653
US

V. Phone/Fax

Practice location:
  • Phone: 904-637-0037
  • Fax:
Mailing address:
  • Phone: 904-422-1566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3942
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberPO3294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: