Provider Demographics
NPI:1528040276
Name:BOBROW, BENTLEY JORDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENTLEY
Middle Name:JORDAN
Last Name:BOBROW
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 1:1133 JOHN FREEMAN BLVD # 270
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2809
Mailing Address - Country:US
Mailing Address - Phone:713-500-7863
Mailing Address - Fax:
Practice Address - Street 1:1133 JOHN FREEMAN BLVD # 270
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2809
Practice Address - Country:US
Practice Address - Phone:713-500-7863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21017207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ170449Medicaid
AZ86080015085259C277OtherTRIWEST
AZ930118000OtherRAILROAD MEDICARE
AZZ69996Medicare PIN