Provider Demographics
NPI:1780602490
Name:KUBISTY, CHERYL A (MD)
Entity type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:A
Last Name:KUBISTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 NE IRELAND
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277
Mailing Address - Country:US
Mailing Address - Phone:360-675-7678
Mailing Address - Fax:360-279-0614
Practice Address - Street 1:830 NE IRELAND
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277
Practice Address - Country:US
Practice Address - Phone:360-675-7678
Practice Address - Fax:360-279-0614
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030606174400000X
IDM-12093207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1108687Medicaid
WA1108687Medicaid
WAAB11065Medicare ID - Type Unspecified