Provider Demographics
NPI:1437264595
Name:BOBERG, JEFFREY STEVEN (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:STEVEN
Last Name:BOBERG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9323 PHOENIX VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-4281
Mailing Address - Country:US
Mailing Address - Phone:636-561-0871
Mailing Address - Fax:636-561-5032
Practice Address - Street 1:9323 PHOENIX VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-4281
Practice Address - Country:US
Practice Address - Phone:636-561-0871
Practice Address - Fax:636-561-5032
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000570213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO302436829Medicaid
MO5031350001OtherDMERC
MOP00081678OtherRAILROAD MEDICARE
IL5031350002OtherDMERC
MOP00081678OtherRAILROAD MEDICARE
MOT39110Medicare UPIN
ILK02920Medicare PIN