Healthcare Provider Details

I. General information

NPI: 1619950086
Provider Name (Legal Business Name): CUBYSON MARCUS OXLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 11/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 QUINCY AVE
SCRANTON PA
18510-1724
US

IV. Provider business mailing address

11781 LEE JACKSON MEMORIAL HWY SUITE 550
FAIRFAX VA
22033-3309
US

V. Phone/Fax

Practice location:
  • Phone: 570-770-5000
  • Fax:
Mailing address:
  • Phone: 571-777-5102
  • Fax: 703-563-6256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD424816
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierP00148665
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRR MEDICARE
# 2
Identifier1011120780002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: