Healthcare Provider Details

I. General information

NPI: 1629544564
Provider Name (Legal Business Name): KURT LEONARD DUBAY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 OLD NEW MILFORD RD STE 3E
BROOKFIELD CT
06804-2414
US

IV. Provider business mailing address

24 APPLEGATE LN
MONROE CT
06468-1264
US

V. Phone/Fax

Practice location:
  • Phone: 203-775-6205
  • Fax:
Mailing address:
  • Phone: 860-830-5735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4694
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: