Provider Demographics
NPI:1720197437
Name:HUBLEY, GROVER CLEVELAND JR (MD)
Entity Type:Individual
Prefix:MR
First Name:GROVER
Middle Name:CLEVELAND
Last Name:HUBLEY
Suffix:JR
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 1:1427 OLD MILL LANE
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77864
Mailing Address - Country:US
Mailing Address - Phone:936-348-3515
Mailing Address - Fax:936-348-3163
Practice Address - Street 1:813 SOUTH STATE STREET SUITE 100
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TX
Practice Address - Zip Code:77864
Practice Address - Country:US
Practice Address - Phone:936-348-3515
Practice Address - Fax:936-348-3163
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4423207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1669557179OtherGROUP NPI
TX93043OtherSCOTT & WHITE
TX130980904Medicaid
TX93043OtherSCOTT & WHITE
1669557179OtherGROUP NPI