Provider Demographics
NPI:1356320238
Name:BOBBA, KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:KUMAR
Middle Name:
Last Name:BOBBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-5100
Mailing Address - Country:US
Mailing Address - Phone:217-554-3000
Mailing Address - Fax:217-554-4807
Practice Address - Street 1:1900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-554-3000
Practice Address - Fax:217-554-4807
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076077A207RC0000X
IN50002924A193400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes193400000XGroupSingle Specialty
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01076077AMedicaid
060061599OtherMEDICARE RAILROAD
F94000Medicare UPIN