Basic Information
| Provider Information | |||||||||
| NPI: | 1114081700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUBAC | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2120 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972082120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418846233 | ||||||||
| FaxNumber: | 5418802840 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 DAGGETT AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418846233 | ||||||||
| FaxNumber: | 5418802840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | MD20381 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 164981 | 05 | OR | MEDICAID | 060060517 | 01 | RAILROAD MEDICARE | OTHER | 060051986 | 01 | RAILROAD MEDICARE | OTHER |