Healthcare Provider Details

I. General information

NPI: 1811211154
Provider Name (Legal Business Name): SAMUEL DOMINIC KOBBA N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2010
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 SIMPSON AVE
ELKHART IN
46516-4666
US

IV. Provider business mailing address

5550 S EAST ST STE C
INDIANAPOLIS IN
46227-1991
US

V. Phone/Fax

Practice location:
  • Phone: 574-293-0052
  • Fax: 574-343-1390
Mailing address:
  • Phone: 317-534-4660
  • Fax: 317-782-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000742A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: