Provider Demographics
NPI:1508889700
Name:KUBOTA, SUSAN Y (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:Y
Last Name:KUBOTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8983 SW ARAPAHO RD
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9355
Mailing Address - Country:US
Mailing Address - Phone:503-330-0477
Mailing Address - Fax:
Practice Address - Street 1:8983 SW ARAPAHO RD
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9355
Practice Address - Country:US
Practice Address - Phone:503-330-0477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17827207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805347000Medicaid
OR050073777OtherRR MEDICARE
OR134370Medicaid
AKMD782ORMedicaid
WA8175911Medicaid
AKMD782ORMedicaid
AKMD782ORMedicaid