Basic Information
| Provider Information | |||||||||
| NPI: | 1326014556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUBIAK | ||||||||
| FirstName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 185 OLD COUNTRY RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312984479 | ||||||||
| FaxNumber: | 6315913047 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 WOODVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SHOREHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117861331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319291256 | ||||||||
| FaxNumber: | 6319298313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 06/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 169449 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01006688 | 05 | NY | MEDICAID |