Provider Demographics
NPI:1033125901
Name:CUBILLO, ENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:CUBILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 WEST MAIN
Mailing Address - Street 2:P.O. BOX 9178
Mailing Address - City:RUSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811
Mailing Address - Country:US
Mailing Address - Phone:479-968-8279
Mailing Address - Fax:479-968-4331
Practice Address - Street 1:3205 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2301
Practice Address - Country:US
Practice Address - Phone:479-968-8279
Practice Address - Fax:479-968-4331
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE26222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARBCBSOtherBCBS PROVIDER NUMBER
ARBCBSOtherBCBS PROVIDER NUMBER
ARA13454Medicare UPIN