Provider Demographics
NPI:1407890601
Name:HUBBARD, KEVIN W (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11434 E MISSION LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-5821
Mailing Address - Country:US
Mailing Address - Phone:480-286-8808
Mailing Address - Fax:
Practice Address - Street 1:11434 E MISSION LN
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-5821
Practice Address - Country:US
Practice Address - Phone:480-286-8808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF36445207P00000X
AZ005913208D00000X
OK2532207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1407890601OtherBLUE SHIELD
MS00124356Medicaid
OK100204600AMedicaid
OKOK401599Medicare PIN
OK100204600AMedicaid