Provider Demographics
NPI:1215937271
Name:BUB, CAROL LISA (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:LISA
Last Name:BUB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 DALTON ST
Mailing Address - Street 2:
Mailing Address - City:EMMAUS
Mailing Address - State:PA
Mailing Address - Zip Code:18049-3031
Mailing Address - Country:US
Mailing Address - Phone:610-628-8200
Mailing Address - Fax:610-965-6595
Practice Address - Street 1:619 DALTON ST
Practice Address - Street 2:
Practice Address - City:EMMAUS
Practice Address - State:PA
Practice Address - Zip Code:18049-3031
Practice Address - Country:US
Practice Address - Phone:610-628-8200
Practice Address - Fax:610-965-6595
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059650L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016133000002Medicaid
875759Medicare ID - Type Unspecified
PA0016133000002Medicaid