Provider Demographics
NPI:1720108012
Name:BOBER, JORG A (DPM)
Entity Type:Individual
Prefix:
First Name:JORG
Middle Name:A
Last Name:BOBER
Suffix:
Gender:M
Credentials:DPM
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 1653
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32067-1653
Mailing Address - Country:US
Mailing Address - Phone:904-422-1566
Mailing Address - Fax:
Practice Address - Street 1:1409 KINGSLEY AVE
Practice Address - Street 2:SUITE 9-G
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4537
Practice Address - Country:US
Practice Address - Phone:904-637-0037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3942213ES0103X
FLPO3294213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6605219OtherCIGNA
FL002908200Medicaid
FL65967OtherBCBS
FL6605219OtherGREAT WEST
FLPO3294OtherFL STATE LICENSE
FL7923937OtherAETNA
FL6605219OtherGREAT WEST
AF852Medicare PIN