Healthcare Provider Details

I. General information

NPI: 1922027218
Provider Name (Legal Business Name): EDWIN SAMUEL KULUBYA M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 LONG BEACH BLVD STE 320
LONG BEACH CA
90807-4025
US

IV. Provider business mailing address

3605 LONG BEACH BLVD STE 320
LONG BEACH CA
90807-4025
US

V. Phone/Fax

Practice location:
  • Phone: 714-234-7485
  • Fax: 714-701-1071
Mailing address:
  • Phone: 714-234-7485
  • Fax: 714-701-1071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberL1100
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberG54189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: