Provider Demographics
NPI:1194943001
Name:KENNETH J. SOBEL, MD
Entity type:Organization
Organization Name:KENNETH J. SOBEL, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:SOBEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-513-2072
Mailing Address - Street 1:575 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 510
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3333
Mailing Address - Country:US
Mailing Address - Phone:770-513-2072
Mailing Address - Fax:770-513-7986
Practice Address - Street 1:575 PROFESSIONAL DR
Practice Address - Street 2:SUITE 510
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3333
Practice Address - Country:US
Practice Address - Phone:770-513-2072
Practice Address - Fax:770-513-7986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024099207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7317Medicare ID - Type Unspecified