Provider Demographics
NPI:1346231818
Name:KUBITZ, MICHAEL LEE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:KUBITZ
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 1:784 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2315
Mailing Address - Country:US
Mailing Address - Phone:360-425-6111
Mailing Address - Fax:360-636-1297
Practice Address - Street 1:784 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2315
Practice Address - Country:US
Practice Address - Phone:360-425-6111
Practice Address - Fax:360-636-1297
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000326482080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR074773Medicaid
WA129610OtherWA LABOR & INDUSTRIES
WA8173031Medicaid
WA8173031Medicaid
WAAB15236Medicare ID - Type Unspecified