Healthcare Provider Details

I. General information

NPI: 1538042767
Provider Name (Legal Business Name): GINA KUBESH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 VILLAGE COMMONS DR STE 102
ST AUGUSTINE FL
32092-4548
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 904-530-9802
  • Fax: 904-530-9809
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC6785
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: