Provider Demographics
NPI:1689654923
Name:KUBO, DOUGLAS J (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
Last Name:KUBO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 15TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-2238
Mailing Address - Country:US
Mailing Address - Phone:916-443-8034
Mailing Address - Fax:916-442-6010
Practice Address - Street 1:2409 15TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-2238
Practice Address - Country:US
Practice Address - Phone:916-443-8034
Practice Address - Fax:916-442-6010
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAT10091152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY34870YMedicaid
CA410015078Medicare PIN
CAT10091Medicare UPIN
CA0298790001Medicare NSC
CADE745AMedicare PIN