Provider Demographics
NPI:1114081700
Name:KUBAC, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:KUBAC
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:PO BOX 2120
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2120
Mailing Address - Country:US
Mailing Address - Phone:541-884-6233
Mailing Address - Fax:541-880-2840
Practice Address - Street 1:3001 DAGGETT AVE STE 101
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1126
Practice Address - Country:US
Practice Address - Phone:541-884-6233
Practice Address - Fax:541-880-2840
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20381207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164981Medicaid
060060517OtherRAILROAD MEDICARE
060051986OtherRAILROAD MEDICARE
ORF52145Medicare UPIN
OR164981Medicaid