Healthcare Provider Details

I. General information

NPI: 1326099136
Provider Name (Legal Business Name): KENNETH L UBBEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CUNNINGHAM COR
BELLA VISTA AR
72714-3520
US

IV. Provider business mailing address

5 CUNNINGHAM COR
BELLA VISTA AR
72714-3520
US

V. Phone/Fax

Practice location:
  • Phone: 479-855-1247
  • Fax: 479-855-1249
Mailing address:
  • Phone: 479-855-1247
  • Fax: 479-855-1249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC-8212
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: