Basic Information
| Provider Information | |||||||||
| NPI: | 1336196724 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUBAK | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5126 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053351952 | ||||||||
| FaxNumber: | 6053739971 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 W 49TH ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571056550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053366385 | ||||||||
| FaxNumber: | 6053366513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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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 | 207RA0201X | 3512 | SD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 0007519 | 01 | SD | BCBS | OTHER | 73Q32BU | 01 | MN | BCBS | OTHER | 5900042 | 05 | SD | MEDICAID | 792302300 | 05 | MN | MEDICAID | 1981852 | 05 | IA | MEDICAID |