Healthcare Provider Details

I. General information

NPI: 1043323702
Provider Name (Legal Business Name): OLDRICH V BUBENIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N WASINGTON STREET
COUNCIL GROVE KS
66846
US

IV. Provider business mailing address

408 S BROADVIEW ST
CAPE GIRARDEAU MO
63703-5725
US

V. Phone/Fax

Practice location:
  • Phone: 620-767-5126
  • Fax:
Mailing address:
  • Phone: 573-332-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR2A65
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: