Provider Demographics
NPI:1790729978
Name:KUBISIAK, DANIEL ROBERT (DPH)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:ROBERT
Last Name:KUBISIAK
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 4000 JAMES H QULLEN VAMC
Mailing Address - Street 2:CORNER OF LAMONT AND SIDNEY
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-3412
Mailing Address - Country:US
Mailing Address - Phone:423-926-1171
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF SIDNEY AND LAMONT STREET
Practice Address - Street 2:JAMES H. QUILLEN VAMC
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4523183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist