Provider Demographics
NPI:1902876964
Name:BOBOVNYIK, DENISE LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:LOUISE
Last Name:BOBOVNYIK
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 1:3660 STUTZ DR
Mailing Address - Street 2:STE 102
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-8149
Mailing Address - Country:US
Mailing Address - Phone:330-702-1585
Mailing Address - Fax:330-702-1383
Practice Address - Street 1:3660 STUTZ DR
Practice Address - Street 2:STE 102
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-8149
Practice Address - Country:US
Practice Address - Phone:330-702-1585
Practice Address - Fax:330-702-1383
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35054533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0703368Medicaid
OHH153520OtherMEDICARE PTAN
OH0703368Medicaid