Provider Demographics
NPI:1982829487
Name:KUBICK, MELISSA (OD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:KUBICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6509
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:11110 MALL CIR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4803
Practice Address - Country:US
Practice Address - Phone:301-705-8383
Practice Address - Fax:301-705-8388
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1316152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU92683Medicare UPIN
MD502M772FMedicare PIN