Provider Demographics
NPI:1891424495
Name:KUBRA, KHADIJA TUL
Entity Type:Individual
Prefix:
First Name:KHADIJA
Middle Name:TUL
Last Name:KUBRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6136 170TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-1900
Mailing Address - Country:US
Mailing Address - Phone:718-709-0940
Mailing Address - Fax:
Practice Address - Street 1:6136 170TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1900
Practice Address - Country:US
Practice Address - Phone:718-709-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP115363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine