Provider Demographics
NPI:1174546717
Name:MOBLEY, KATHLEEN (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MOBLEY
Suffix:
Gender:F
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:PO BOX 60100
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29419-0100
Mailing Address - Country:US
Mailing Address - Phone:800-664-3939
Mailing Address - Fax:
Practice Address - Street 1:11375 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5409
Practice Address - Country:US
Practice Address - Phone:305-665-4614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51280207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04287OtherBLUE CROSS BLUE SHIELD
FL036185200Medicaid
FL04287ZMedicare PIN
FL036185200Medicaid
220008196Medicare PIN
FLA65169Medicare UPIN