Provider Demographics
NPI:1194863902
Name:LUBISICH, JOHN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:LUBISICH
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 1:150 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2005
Practice Address - Country:US
Practice Address - Phone:866-558-4320
Practice Address - Fax:619-294-8399
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001614962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO173098OtherMO BLUE SHIELD
AR98753OtherARK BLUE SHIELD
MO205079403Medicaid
AR142019001Medicaid
WAG8878527Medicare PIN
CAWG77575CMedicare PIN
CAWG77575AMedicare PIN
CAWG7757DMedicare PIN
MO173098OtherMO BLUE SHIELD
G78221Medicare UPIN
MO205079403Medicaid
AR142019001Medicaid