Provider Demographics
NPI:1871529024
Name:TOLOSA, BOBBY (MD)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:TOLOSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 NEW VISION DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 N SAWYER RD
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-2572
Practice Address - Country:US
Practice Address - Phone:260-347-8030
Practice Address - Fax:260-347-8035
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32336207V00000X
NE20152207V00000X
IN01078773A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025323300Medicaid
IA2169730Medicaid
G66825Medicare UPIN
NE10025323300Medicaid