Provider Demographics
NPI:1073511978
Name:LAFFERTY, BOBBY R (DO)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:R
Last Name:LAFFERTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5042
Mailing Address - Country:US
Mailing Address - Phone:386-328-8371
Mailing Address - Fax:386-328-8371
Practice Address - Street 1:1302 RIVER ST
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-5042
Practice Address - Country:US
Practice Address - Phone:386-328-8371
Practice Address - Fax:386-312-0775
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1716207Q00000X
FLOS9833207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2007104000Medicaid
BO0883814Medicare ID - Type Unspecified
H03067Medicare UPIN