Provider Demographics
NPI:1710229315
Name:BOBO, EZRA RALPH (MD)
Entity Type:Individual
Prefix:DR
First Name:EZRA
Middle Name:RALPH
Last Name:BOBO
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 1:76 PARK ROW
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-2524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:994 W SHERMAN AVE BLDG 2
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6937
Practice Address - Country:US
Practice Address - Phone:631-534-7246
Practice Address - Fax:856-457-5681
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2019-05812085R0204X
390200000X
NJ25MA100093002085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program