Provider Demographics
NPI:1295745180
Name:KUBO, KOJI (MD)
Entity type:Individual
Prefix:DR
First Name:KOJI
Middle Name:
Last Name:KUBO
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:PO BOX 10968
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0968
Mailing Address - Country:US
Mailing Address - Phone:805-988-8058
Mailing Address - Fax:805-983-0803
Practice Address - Street 1:1700 N ROSE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3790
Practice Address - Country:US
Practice Address - Phone:805-988-8058
Practice Address - Fax:805-983-0803
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95628207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1295745180Medicaid
CA1831365667Medicaid
CAZZZ50355YOtherBS/TRIWEST
CA00A956280Medicaid
CA1295745180Medicaid
CAW21724Medicare PIN