Provider Demographics
NPI:1790721603
Name:TOLOSA OB GYN PC
Entity Type:Organization
Organization Name:TOLOSA OB GYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACOG
Authorized Official - Phone:712-388-2670
Mailing Address - Street 1:800 MERCY DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-3128
Mailing Address - Country:US
Mailing Address - Phone:712-388-2670
Mailing Address - Fax:
Practice Address - Street 1:800 MERCY DR
Practice Address - Street 2:SUITE 5
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-3128
Practice Address - Country:US
Practice Address - Phone:712-388-2670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32336207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0788521Medicaid
NE10025323300Medicaid
IAI16688Medicare ID - Type Unspecified
NE10025323300Medicaid