Provider Demographics
NPI:1871690115
Name:DUBBERKE, LANCE DIETER (MD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:DIETER
Last Name:DUBBERKE
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 1:686 S PIKE ST
Mailing Address - Street 2:STE A
Mailing Address - City:SHINNSTON
Mailing Address - State:WV
Mailing Address - Zip Code:26431-1043
Mailing Address - Country:US
Mailing Address - Phone:304-624-4655
Mailing Address - Fax:304-624-3918
Practice Address - Street 1:686 S PIKE ST
Practice Address - Street 2:
Practice Address - City:SHINNSTON
Practice Address - State:WV
Practice Address - Zip Code:26431-1043
Practice Address - Country:US
Practice Address - Phone:304-592-2100
Practice Address - Fax:304-592-2102
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0052728000Medicaid
WV0791273Medicare PIN
WV0052728000Medicaid