Provider Demographics
NPI:1073550950
Name:KOBOBEL, JASEN S (MD)
Entity Type:Individual
Prefix:DR
First Name:JASEN
Middle Name:S
Last Name:KOBOBEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JASEN
Other - Middle Name:S
Other - Last Name:KOBOBEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1950 ROCKLEDGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3763
Mailing Address - Country:US
Mailing Address - Phone:321-636-0005
Mailing Address - Fax:321-636-9030
Practice Address - Street 1:1950 ROCKLEDGE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2728
Practice Address - Country:US
Practice Address - Phone:321-636-0005
Practice Address - Fax:321-636-9030
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266689800Medicaid
FL41918Medicare ID - Type Unspecified
FLH80149Medicare UPIN