Provider Demographics
NPI:1003903832
Name:KUBEK, DOUGLAS CARL (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:CARL
Last Name:KUBEK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21000 E 12 MILE RD
Mailing Address - Street 2:STE 111
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1156
Mailing Address - Country:US
Mailing Address - Phone:586-263-7400
Mailing Address - Fax:586-326-3161
Practice Address - Street 1:21000 E 12 MILE RD
Practice Address - Street 2:STE 111
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1156
Practice Address - Country:US
Practice Address - Phone:586-779-7610
Practice Address - Fax:586-779-1391
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012806207YS0012X, 207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0455010215OtherBCBSM
MI14075OtherMCARE
040E061920OtherBLUE SHIELD
MI133060OtherCARE CHOICES
MI104200OtherGREAT LAKES HMO
MI4535235Medicaid
MIH09050Medicare UPIN
040E061920OtherBLUE SHIELD
MI0E061920Medicare PIN