Provider Demographics
NPI:1427340454
Name:LOBO, BRIAN CLYDE
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:CLYDE
Last Name:LOBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-3003
Mailing Address - Country:US
Mailing Address - Phone:352-273-5199
Mailing Address - Fax:352-392-6781
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0001
Practice Address - Country:US
Practice Address - Phone:352-273-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH128442207Y00000X
FLME132089207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
JB658ZOtherMEDICARE PTAN
FL021845000Medicaid