Provider Demographics
NPI:1437299724
Name:BOBO, ANDRE' TYRONE (MD)
Entity Type:Individual
Prefix:
First Name:ANDRE'
Middle Name:TYRONE
Last Name:BOBO
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 1:1532 LONE OAK RD STE 245
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7941
Mailing Address - Country:US
Mailing Address - Phone:270-538-5700
Mailing Address - Fax:
Practice Address - Street 1:1532 LONE OAK RD STE 245
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7941
Practice Address - Country:US
Practice Address - Phone:270-538-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD213166207V00000X
MI430166276207V00000X
WI100764-875207V00000X
KYTP969207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160H232190OtherBCBSM/BCN
MI104728939Medicaid
MI160H232190OtherBCBSM/BCN
MI104728939Medicaid