Provider Demographics
NPI:1013904168
Name:CUBBAGE, BRIAN KEITH (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:CUBBAGE
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 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 SHADY LN
Practice Address - Street 2:
Practice Address - City:WHITE STONE
Practice Address - State:VA
Practice Address - Zip Code:22578-2601
Practice Address - Country:US
Practice Address - Phone:804-435-3133
Practice Address - Fax:804-435-1311
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232462207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1013904168Medicaid
H63498Medicare UPIN
VAP00616662Medicare PIN
VA017648K53Medicare PIN