Provider Demographics
NPI:1922027218
Name:KULUBYA, EDWIN SAMUEL (M D)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:SAMUEL
Last Name:KULUBYA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 LONG BEACH BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-4025
Mailing Address - Country:US
Mailing Address - Phone:714-234-7485
Mailing Address - Fax:714-701-1071
Practice Address - Street 1:3605 LONG BEACH BLVD STE 320
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4025
Practice Address - Country:US
Practice Address - Phone:714-234-7485
Practice Address - Fax:714-701-1071
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1100207L00000X
CAG54189208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159375801Medicaid
TX8A6206Medicare ID - Type Unspecified
TX159375801Medicaid
CACB235733Medicare UPIN