Provider Demographics
NPI:1164405882
Name:KUBBA, SAMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:
Last Name:KUBBA
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 1:401 E HIGHLAND AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3834
Mailing Address - Country:US
Mailing Address - Phone:909-886-6806
Mailing Address - Fax:909-883-8132
Practice Address - Street 1:401 E HIGHLAND AVE STE C
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3834
Practice Address - Country:US
Practice Address - Phone:909-886-6806
Practice Address - Fax:909-883-8132
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71807207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA900003252OtherRAILROAD MEDICARE
CA00A718070Medicaid
CA00A718070Medicare PIN