Provider Demographics
NPI:1629174222
Name:BUBANIC, BERNARD P (DC DACBSP)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:P
Last Name:BUBANIC
Suffix:
Gender:M
Credentials:DC DACBSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4082 FULTON DRIVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718
Mailing Address - Country:US
Mailing Address - Phone:330-491-8100
Mailing Address - Fax:844-572-2173
Practice Address - Street 1:4082 FULTON DRIVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718
Practice Address - Country:US
Practice Address - Phone:330-491-8100
Practice Address - Fax:844-572-2173
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1307111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0701351Medicaid
T48598Medicare UPIN
OH0701351Medicaid