Provider Demographics
NPI:1750449286
Name:KUBICHEK, MARILYN ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:ANN
Last Name:KUBICHEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-0564
Mailing Address - Country:US
Mailing Address - Phone:973-377-7822
Mailing Address - Fax:973-377-7821
Practice Address - Street 1:256 COLUMBIA TPKE
Practice Address - Street 2:SUITE 109
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1209
Practice Address - Country:US
Practice Address - Phone:973-377-7822
Practice Address - Fax:973-377-7821
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA060670002084N0402X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG22679Medicare UPIN
NJ543459SM9Medicare ID - Type Unspecified