Basic Information
| Provider Information | |||||||||
| NPI: | 1871563528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOBY | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD STE 4015 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 4203 BELFORT RD STE 345 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322161469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506461 | ||||||||
| FaxNumber: | 9044506469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 03/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 834 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 550691297 | 01 | WV | SELECT NET | OTHER | 550691297 | 01 | WV | TRICARE | OTHER | 550691297 | 01 | WV | 4 MOST | OTHER | 636453934A | 05 | GA | MEDICAID | 001712511 | 01 | WV | BLUE CROSS | OTHER | 3810000999 | 05 | WV | MEDICAID | 2930625-00 | 05 | FL | MEDICAID |