Provider Demographics
NPI:1609877968
Name:SOBONG, ENRICO C (MD)
Entity Type:Individual
Prefix:
First Name:ENRICO
Middle Name:C
Last Name:SOBONG
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 1:620 GOLD CANYON DR
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-5902
Mailing Address - Country:US
Mailing Address - Phone:616-954-9800
Mailing Address - Fax:616-954-2116
Practice Address - Street 1:1180 N INDIAN CANYON DR
Practice Address - Street 2:STE E 218
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4835
Practice Address - Country:US
Practice Address - Phone:760-416-4866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037733174400000X, 207RX0202X
CAC53891174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900004368OtherRR MEDICARE
MIM08620011Medicare PIN
A76402Medicare UPIN
MIA76402Medicare UPIN
MI900004368OtherRR MEDICARE