Healthcare Provider Details

I. General information

NPI: 1710060066
Provider Name (Legal Business Name): JYOTHIRMAI BOBBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 11/27/2023
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5973 BEATRICE DR
KALAMAZOO MI
49009-9583
US

IV. Provider business mailing address

5943 STADIUM DR SUITE 1
KALAMAZOO MI
49009-3016
US

V. Phone/Fax

Practice location:
  • Phone: 269-286-7110
  • Fax: 269-286-7111
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301079796
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301079796
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: