Provider Demographics
NPI:1619059334
Name:MOBLEY, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
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 1:154 BOGLE OFFICE PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2810
Mailing Address - Country:US
Mailing Address - Phone:606-676-0455
Mailing Address - Fax:606-425-4696
Practice Address - Street 1:404 WAGNER AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-2537
Practice Address - Country:US
Practice Address - Phone:937-548-8711
Practice Address - Fax:937-548-6724
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35068284208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0137186Medicaid
OHMO0780473Medicare ID - Type UnspecifiedOHIO INDIVIDUAL MEDICARE
OH0137186Medicaid