Provider Demographics
NPI:1114097896
Name:CHUBAK, GARY S (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
Last Name:CHUBAK
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 1:21418 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2219
Mailing Address - Country:US
Mailing Address - Phone:718-428-6000
Mailing Address - Fax:718-423-5102
Practice Address - Street 1:21418 24TH AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-2219
Practice Address - Country:US
Practice Address - Phone:718-428-6000
Practice Address - Fax:718-423-5102
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127280207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00434331Medicaid
NY00434331Medicaid
NY80701Medicare PIN