=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376002675
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY BUBLEY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2019
-----------------------------------------------------
Last Update Date | 05/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6700 WEST LOOP SOUTH SUITE #500
-----------------------------------------------------
City | BELLAIRE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-778-7777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9240 N SAM HOUSTON PKWY E STE 201
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77396-5141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | U3801
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | U3801
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------