Healthcare Provider Details

I. General information

NPI: 1003903832
Provider Name (Legal Business Name): DOUGLAS CARL KUBEK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 E 12 MILE RD STE 111
SAINT CLAIR SHORES MI
48081-1156
US

IV. Provider business mailing address

21000 E 12 MILE RD STE 111
SAINT CLAIR SHORES MI
48081-1156
US

V. Phone/Fax

Practice location:
  • Phone: 586-779-7610
  • Fax: 586-779-1391
Mailing address:
  • Phone: 586-263-7400
  • Fax: 586-326-3161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number5101012806
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number5101012806
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: