Healthcare Provider Details

I. General information

NPI: 1679784664
Provider Name (Legal Business Name): MICHAEL BUBLIK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S CENTRAL AVE STE 101B
GLENDALE CA
91204-4375
US

IV. Provider business mailing address

800 S CENTRAL AVE STE 101B
GLENDALE CA
91204-4375
US

V. Phone/Fax

Practice location:
  • Phone: 818-649-1433
  • Fax: 818-649-1436
Mailing address:
  • Phone: 818-649-1433
  • Fax: 818-649-1436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberA112615
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: