Healthcare Provider Details

I. General information

NPI: 1528852837
Provider Name (Legal Business Name): WASSIL MOHAMED KOUBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 MEETING HOUSE LANE MEDICAL EDUCATION DEPARTMENT
SOUTHAMPTON NY
11968
US

IV. Provider business mailing address

240 MEETING HOUSE LANE MEDICAL EDUCATION DEPARTMENT
SOUTHAMPTON NY
11968
US

V. Phone/Fax

Practice location:
  • Phone: 631-723-6141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: