Healthcare Provider Details

I. General information

NPI: 1235174111
Provider Name (Legal Business Name): SAMANTHA MEHTA KUBASKA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24401 CALLE DE LA LOUISA STE 200
LAGUNA HILLS CA
92653
US

IV. Provider business mailing address

PO BOX 51787
LOS ANGELES CA
90051-6087
US

V. Phone/Fax

Practice location:
  • Phone: 949-452-7200
  • Fax: 949-464-0720
Mailing address:
  • Phone: 949-452-7200
  • Fax: 949-464-0720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberA79054
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberA79054
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA79054
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: