Healthcare Provider Details

I. General information

NPI: 1073676979
Provider Name (Legal Business Name): KATHLEEN ROSE MCCUBBIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

599 WINTHROP ST
BROOKLYN NY
11203
US

IV. Provider business mailing address

599 WINTHROP ST
BROOKLYN NY
11203
US

V. Phone/Fax

Practice location:
  • Phone: 718-604-4464
  • Fax:
Mailing address:
  • Phone: 718-604-4464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number256168
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number060-0003387
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: