Healthcare Provider Details

I. General information

NPI: 1487875373
Provider Name (Legal Business Name): JOHN B. HUBBARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

PO BOX 602658
CHARLOTTE NC
28260-2658
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2255
  • Fax: 336-903-7841
Mailing address:
  • Phone: 336-716-2255
  • Fax: 336-903-7841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number2007-00765
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: