Provider Demographics
NPI:1417903212
Name:DOBLIN, BRUCE H (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:H
Last Name:DOBLIN
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 1:2500 RIDGE AVE
Mailing Address - Street 2:#210
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2455
Mailing Address - Country:US
Mailing Address - Phone:847-328-6440
Mailing Address - Fax:847-328-6473
Practice Address - Street 1:2500 RIDGE AVE
Practice Address - Street 2:#210
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2455
Practice Address - Country:US
Practice Address - Phone:847-328-6440
Practice Address - Fax:847-328-6473
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074034207R00000X
IL3366037583207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL336-0377583OtherIL STATE LICENSE
IL036074034Medicaid
IL336-0377583OtherIL STATE LICENSE
ILE21627Medicare UPIN
ILK12473Medicare PIN
ILBD5966328OtherDEA