Provider Demographics
NPI:1902805013
Name:BOBER, MITCHELL (DO)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:BOBER
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 1:181 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PENNSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08070-1550
Mailing Address - Country:US
Mailing Address - Phone:856-678-9002
Mailing Address - Fax:856-678-4027
Practice Address - Street 1:181 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-1550
Practice Address - Country:US
Practice Address - Phone:856-678-9002
Practice Address - Fax:856-678-4027
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB044548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1218905Medicaid
NJP00712354OtherRR MEDICARE
NJ478127U62Medicare PIN
NJP00712354OtherRR MEDICARE