Provider Demographics
NPI:1851829584
Name:KUBIS, BRADLEY ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ROBERT
Last Name:KUBIS
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 1:1100 BOARDMAN CANFIELD RD APT 64B
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-8056
Mailing Address - Country:US
Mailing Address - Phone:412-974-8859
Mailing Address - Fax:
Practice Address - Street 1:34 BOARDMAN POLAND RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4601
Practice Address - Country:US
Practice Address - Phone:330-758-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6554152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist