Provider Demographics
NPI:1790763696
Name:KOBAK, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KOBAK
Suffix:
Gender:F
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:PO BOX 30170
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-7170
Mailing Address - Country:US
Mailing Address - Phone:302-623-0100
Mailing Address - Fax:
Practice Address - Street 1:200 HYGEIA DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2049
Practice Address - Country:US
Practice Address - Phone:302-623-0100
Practice Address - Fax:302-623-0147
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10003064207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE017502C90Medicare UPIN
DED24780Medicare UPIN
DE017502C90Medicare PIN