Provider Demographics
NPI:1073676979
Name:MCCUBBIN, KATHLEEN ROSE (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ROSE
Last Name:MCCUBBIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 WINTHROP ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203
Mailing Address - Country:US
Mailing Address - Phone:718-604-4464
Mailing Address - Fax:
Practice Address - Street 1:599 WINTHROP ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203
Practice Address - Country:US
Practice Address - Phone:718-604-4464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256168207ZF0201X
VT060-0003387390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program