Basic Information
| Provider Information | |||||||||
| NPI: | 1831354810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUBANKS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MIKEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5750 W THUNDERBIRD RD STE B200 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853064664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023751700 | ||||||||
| FaxNumber: | 6029781225 | ||||||||
| Practice Location | |||||||||
| Address1: | 5750 W THUNDERBIRD RD STE B200 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853064664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023751700 | ||||||||
| FaxNumber: | 6029781225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2008 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
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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 | 208800000X | 51942 | MN | N | Allopathic & Osteopathic Physicians | Urology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208800000X | 47163 | AZ | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | IA | MEDICAID | 780254 | 05 | AZ | MEDICAID | ENROLLED | 05 | MN | MEDICAID | P00970223 | 01 | MN | RAILROAD MEDICARE | OTHER |