Provider Demographics
NPI:1356326516
Name:SOBOTKA, JON DUANE (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:DUANE
Last Name:SOBOTKA
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 1:621 NW 35TH ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4914
Mailing Address - Country:US
Mailing Address - Phone:541-740-8846
Mailing Address - Fax:
Practice Address - Street 1:530 NW 27TH ST
Practice Address - Street 2:BENTON COUNTY HEALTH DEPARTMENT
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5223
Practice Address - Country:US
Practice Address - Phone:541-766-6835
Practice Address - Fax:541-766-6186
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 155222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023192Medicaid
ORC 94170Medicare UPIN