Provider Demographics
NPI:1528034212
Name:MOBLEY, ELIJAH (MD)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:MOBLEY
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 1:20258 US HIGHWAY 18
Mailing Address - Street 2:PMB 514 STE 430
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-6197
Mailing Address - Country:US
Mailing Address - Phone:760-946-0100
Mailing Address - Fax:760-946-3176
Practice Address - Street 1:15366 11TH ST STE Q
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3726
Practice Address - Country:US
Practice Address - Phone:760-241-6201
Practice Address - Fax:760-241-6203
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5725204F00000X
CACA286A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6631230Medicaid
SD6631230Medicaid
SD100588Medicare ID - Type Unspecified