Provider Demographics
NPI:1073179784
Name:KUBAT, BROOKE
Entity type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:
Last Name:KUBAT
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:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PLAZA DR STE 205
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3044
Practice Address - Country:US
Practice Address - Phone:916-773-8711
Practice Address - Fax:916-503-7693
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-114832084N0400X
CAA1986192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology