Provider Demographics
NPI:1457542631
Name:JUBANG, MICHAEL JEREMY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JEREMY
Last Name:JUBANG
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 1:23 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-1156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N. ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-0462
Practice Address - Country:US
Practice Address - Phone:570-271-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0028963207RA0000X
PAMD4413792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4651659625OtherMYUTMB 4651659625