MEDICARE: SHELBY LUCILLE KUBICKI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207N00000X	Dermatology Physician	01094535A	IN

General Provider Information

NPI Number	:	1043770746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY LUCILLE KUBICKI MD

Provider Business Mailing Address
First Line	:	317 E 17TH ST FL 2
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10003-3804
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6655 TRAVIS ST STE 600
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-1341
Country	:	US
Telephone Number	:	713-500-8268
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2019
Last Update Date	:	10/14/2024

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