Provider Demographics
NPI:1801329412
Name:KUBIAK, KELLY M (DPM)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:KUBIAK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 RIFFEL RD STE A
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-8592
Mailing Address - Country:US
Mailing Address - Phone:440-856-5958
Mailing Address - Fax:
Practice Address - Street 1:784 MEDINA RD STE 107
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-9634
Practice Address - Country:US
Practice Address - Phone:330-591-9635
Practice Address - Fax:330-591-4150
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003911213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery