Provider Demographics
NPI:1063567873
Name:AYCOCK, BOBBY GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:GLENN
Last Name:AYCOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:GLENN
Other - Last Name:AYCOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1855 SAN MIGUEL DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5279
Mailing Address - Country:US
Mailing Address - Phone:925-937-8377
Mailing Address - Fax:925-937-8384
Practice Address - Street 1:1855 SAN MIGUEL DR
Practice Address - Street 2:SUITE 4
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5279
Practice Address - Country:US
Practice Address - Phone:925-937-8377
Practice Address - Fax:925-937-8384
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44291208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD28843Medicare UPIN