Provider Demographics
NPI:1063647642
Name:STUBER, KENT DAVID (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:DAVID
Last Name:STUBER
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 1:3976 UNIVERSITY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4644
Mailing Address - Country:US
Mailing Address - Phone:907-729-2083
Mailing Address - Fax:907-729-1557
Practice Address - Street 1:3976 UNIVERSITY LAKE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4644
Practice Address - Country:US
Practice Address - Phone:907-729-2083
Practice Address - Fax:907-729-1557
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27191207R00000X
AK125925207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1063647642Medicaid