Provider Demographics
NPI:1912121799
Name:HUBBARD, RICHARD HENRY (MD, JD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:HENRY
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:MD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E BIRCH ST STE 5
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-5925
Mailing Address - Country:US
Mailing Address - Phone:760-357-0337
Mailing Address - Fax:760-357-0311
Practice Address - Street 1:801 E BIRCH ST STE 5
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-5925
Practice Address - Country:US
Practice Address - Phone:760-357-0337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC31257174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34498Medicare UPIN
CAGE362AMedicare PIN