Provider Demographics
NPI:1932288628
Name:GUBA, RUSSELL F JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:F
Last Name:GUBA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:220 KNICKERBOCKER ROAD
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-1827
Mailing Address - Country:US
Mailing Address - Phone:201-568-2020
Mailing Address - Fax:201-568-4213
Practice Address - Street 1:220 KNICKERBOCKER ROAD
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626-1827
Practice Address - Country:US
Practice Address - Phone:201-568-2020
Practice Address - Fax:201-568-4213
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA43638207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ519697OtherMEDICARE PTAN
C56653Medicare UPIN