Provider Demographics
NPI:1790754489
Name:BOBELL, JENNIFER R (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:BOBELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:ANTHONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1145 E CLARK AVE
Mailing Address - Street 2:STE F
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-5105
Mailing Address - Country:US
Mailing Address - Phone:805-934-5140
Mailing Address - Fax:805-934-3500
Practice Address - Street 1:1145 E CLARK AVE
Practice Address - Street 2:STE F
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-5105
Practice Address - Country:US
Practice Address - Phone:805-934-5140
Practice Address - Fax:805-934-3500
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-110131207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL626467OtherHEALTHLINK
ILCF3444OtherMEDICARE RAILROAD
IL10032052OtherBC BS
IL036110131Medicaid
IL088669OtherHEALTH ALLIANCE
ILCF3444OtherMEDICARE RAILROAD
IL036110131Medicaid
IL640701Medicare PIN
IL10032052OtherBC BS
IL141840Medicare Oscar/Certification
ILK03762Medicare PIN