Provider Demographics
NPI:1497755391
Name:KUBALA, MARK J (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:KUBALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5235 MERLOT DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-2577
Mailing Address - Country:US
Mailing Address - Phone:409-781-8426
Mailing Address - Fax:
Practice Address - Street 1:5235 MERLOT DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-2577
Practice Address - Country:US
Practice Address - Phone:409-781-8426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC0720207T00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140007873OtherRAILROAD MEDICARE
TX125802205Medicaid
TX4364874OtherAETNA
TX2824444001OtherCIGNA
TX8F3760OtherBCBS
TX148913001Medicaid
TX0020HDOtherGROUP BCBS
TXA003OtherTRICARE CHAMPUS
TXA003OtherTRICARE CHAMPUS
TX8F3760OtherBCBS
TXB24158Medicare UPIN