Provider Demographics
NPI:1821086729
Name:KUBACAK, STEPHANIE ALEXANDRA (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ALEXANDRA
Last Name:KUBACAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ALEXANDRA
Other - Last Name:HUSKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8050 E HIGHWAY 191 STE 200
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-8607
Mailing Address - Country:US
Mailing Address - Phone:432-337-5411
Mailing Address - Fax:
Practice Address - Street 1:8050 E HIGHWAY 191 STE 200
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79765-8607
Practice Address - Country:US
Practice Address - Phone:432-337-5411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8779207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CR485OtherBCBS
TX168108203Medicaid
TXTXB115973Medicare PIN
I16944Medicare UPIN