Healthcare Provider Details

I. General information

NPI: 1679531479
Provider Name (Legal Business Name): GEMILA H BOUBER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GEMILA HASSAN

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 E JEFFERSON ST
CHARLOTTESVILLE VA
22902-5354
US

IV. Provider business mailing address

1011 E JEFFERSON ST
CHARLOTTESVILLE VA
22902-5354
US

V. Phone/Fax

Practice location:
  • Phone: 434-296-9161
  • Fax:
Mailing address:
  • Phone: 340-296-4916
  • Fax: 585-336-4845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101246875
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number221757
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: