Provider Demographics
NPI:1245297969
Name:KUBOTA, MARSHALL KEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:KEN
Last Name:KUBOTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:495 TESCONI CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4619
Mailing Address - Country:US
Mailing Address - Phone:707-419-7904
Mailing Address - Fax:707-545-2313
Practice Address - Street 1:495 TESCONI CIR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4619
Practice Address - Country:US
Practice Address - Phone:707-419-7904
Practice Address - Fax:707-545-2313
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43681207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G436810Medicaid
CA00G436810Medicaid
A49427Medicare UPIN