Provider Demographics
NPI:1235429655
Name:KUBIC, GEORGIA BLACKWOOD (MD)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:BLACKWOOD
Last Name:KUBIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GEORGIA
Other - Middle Name:LEEANN
Other - Last Name:BLACKWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2232 HAVERSHAM CLOSE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1151
Mailing Address - Country:US
Mailing Address - Phone:757-630-4046
Mailing Address - Fax:
Practice Address - Street 1:375 CHIPETA WAY
Practice Address - Street 2:UNIVERSITY OF UTAH FAMILY MEDICINE RESIDENCY
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1260
Practice Address - Country:US
Practice Address - Phone:801-587-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8406695-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine