Provider Demographics
NPI:1396879284
Name:GUBA, ALEXANDER M (MD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:M
Last Name:GUBA
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 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5741
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:6569 N CHARLES ST
Practice Address - Street 2:SUITE 707
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6831
Practice Address - Country:US
Practice Address - Phone:410-821-8181
Practice Address - Fax:410-821-0790
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0016496174400000X
WI18328208200000X
SC39832208200000X
WI71689208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB70272Medicare UPIN