Provider Demographics
NPI:1801895784
Name:HUBBARD, NED B (OD)
Entity type:Individual
Prefix:
First Name:NED
Middle Name:B
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-0146
Mailing Address - Country:US
Mailing Address - Phone:309-852-2236
Mailing Address - Fax:
Practice Address - Street 1:109 N TREMONT ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-0146
Practice Address - Country:US
Practice Address - Phone:309-852-2236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007695152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007695Medicaid
363804415OtherTRICARE
P00129861OtherRR MEDICARE
0478640001Medicare NSC
363804415OtherTRICARE
IL748570Medicare PIN