Healthcare Provider Details

I. General information

NPI: 1184187627
Provider Name (Legal Business Name): JEFFREY MICHAEL KUBIAK MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 YORK AVE # F-7
NEW YORK NY
10065-4805
US

IV. Provider business mailing address

320 E 54TH ST APT 4C
NEW YORK NY
10022-5043
US

V. Phone/Fax

Practice location:
  • Phone: 215-906-9559
  • Fax:
Mailing address:
  • Phone: 215-906-9559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZM0300X
TaxonomyMedical Microbiology Physician
License Number73840
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number313919
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: