Provider Demographics
NPI:1760540736
Name:KUBRAK, ERIC JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JOHN
Last Name:KUBRAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13101 ALLEN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2216
Mailing Address - Country:US
Mailing Address - Phone:734-785-7714
Mailing Address - Fax:734-287-1679
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7714
Practice Address - Fax:734-287-1679
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010542842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F04771Medicare UPIN
MI2608270952Medicare ID - Type Unspecified