Provider Demographics
NPI:1811962780
Name:BOBBY, VINCENT J (DO)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:J
Last Name:BOBBY
Suffix:
Gender:M
Credentials:DO
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 517
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-0517
Mailing Address - Country:US
Mailing Address - Phone:570-450-0870
Mailing Address - Fax:570-450-0874
Practice Address - Street 1:426 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-3361
Practice Address - Country:US
Practice Address - Phone:570-450-0870
Practice Address - Fax:570-450-0874
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005672L207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011443820002Medicaid
PA0011443820002Medicaid
PA539859Medicare PIN