Provider Demographics
NPI:1588676910
Name:BOBER, JEFFREY LEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LEE
Last Name:BOBER
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 1:12 CRAIN HWY S
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3526
Mailing Address - Country:US
Mailing Address - Phone:410-761-9606
Mailing Address - Fax:443-628-0239
Practice Address - Street 1:12 CRAIN HWY S
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3526
Practice Address - Country:US
Practice Address - Phone:410-761-9606
Practice Address - Fax:443-628-0239
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1060213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD092378800Medicaid
MDU09897Medicare UPIN
MD0752730001Medicare NSC
MD092378800Medicaid