Basic Information
| Provider Information | |||||||||
| NPI: | 1851336150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STUBBE | ||||||||
| FirstName: | HERMANN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 N CORPORATE LAKES BLVD | ||||||||
| Address2: | |||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333263211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543491111 | ||||||||
| FaxNumber: | 9543491234 | ||||||||
| Practice Location | |||||||||
| Address1: | 1825 N CORPORATE LAKES BLVD | ||||||||
| Address2: | |||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333263211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543491111 | ||||||||
| FaxNumber: | 9543491234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 04/09/2008 | ||||||||
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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 | 207QG0300X | ME1004444 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QG0300X | 14135 | PR | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0020886ST | 01 | PR | TRIPLES PROVIDER NUMBER | OTHER | 280158200 | 05 | FL | MEDICAID |