Healthcare Provider Details

I. General information

NPI: 1285093104
Provider Name (Legal Business Name): KYLE JUSTIN DUBOSE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2016
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 75TH ST
KENOSHA WI
53142-7884
US

IV. Provider business mailing address

2901 W KINNICKINNIC RIVER PKWY STE 309
MILWAUKEE WI
53215-3660
US

V. Phone/Fax

Practice location:
  • Phone: 262-942-5600
  • Fax: 262-948-7388
Mailing address:
  • Phone: 414-649-1292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number67393
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: