1982050993 NPI number — DR. DERRICK T DUBE D.C.

Table of content: DR. DERRICK T DUBE D.C. (NPI 1982050993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982050993 NPI number — DR. DERRICK T DUBE D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUBE
Provider First Name:
DERRICK
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982050993
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2470 S VAL VISTA DR
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85295-1693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-592-4193
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8016 STATE LINE RD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
PRAIRIE VILLAGE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66208-3721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-826-6837
Provider Business Practice Location Address Fax Number:
913-341-4301
Provider Enumeration Date:
05/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  8720 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 81-2039071 . This is a "FEDERAL TAX IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01-05796 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 8247108 . This is a "EIN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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