Healthcare Provider Details

I. General information

NPI: 1871529024
Provider Name (Legal Business Name): BOBBY TOLOSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N SAWYER RD
KENDALLVILLE IN
46755-2572
US

IV. Provider business mailing address

3702 NEW VISION DR BLDG B
FORT WAYNE IN
46845-1703
US

V. Phone/Fax

Practice location:
  • Phone: 260-347-8030
  • Fax: 260-347-8035
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number32336
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20152
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01078773A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: