Healthcare Provider Details

I. General information

NPI: 1245224302
Provider Name (Legal Business Name): IVAN BUB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 KEISER BLVD
WYOMISSING PA
19610-3333
US

IV. Provider business mailing address

2610 KEISER BLVD
WYOMISSING PA
19610-3333
US

V. Phone/Fax

Practice location:
  • Phone: 610-775-3316
  • Fax: 610-796-2962
Mailing address:
  • Phone: 610-775-3316
  • Fax: 610-796-2962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD040616L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: