Provider Demographics
NPI:1720137615
Name:DUBICK, FRED H
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:H
Last Name:DUBICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3808 RIVERSIDE DR
Mailing Address - Street 2:#100
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505
Mailing Address - Country:US
Mailing Address - Phone:818-843-2214
Mailing Address - Fax:818-843-4331
Practice Address - Street 1:3808 RIVERSIDE DR
Practice Address - Street 2:#100
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-843-2214
Practice Address - Fax:818-843-4331
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6901TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0004692Medicaid
CAGR0004692Medicaid
T70152Medicare UPIN
CAWOP6901CMedicare PIN