Healthcare Provider Details

I. General information

NPI: 1417991530
Provider Name (Legal Business Name): MICHAEL CHARLES BUBEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MICHAEL CHARLES BUBEN D.O.

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 ALDER ST
SOUTH BEND WA
98586-4900
US

IV. Provider business mailing address

PO BOX 269
SOUTH BEND WA
98586-0269
US

V. Phone/Fax

Practice location:
  • Phone: 360-875-5579
  • Fax: 360-875-5235
Mailing address:
  • Phone: 360-875-5579
  • Fax: 360-875-5235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00001152
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberOP00001152
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: