Provider Demographics
NPI:1285093104
Name:DUBOSE, KYLE JUSTIN (DO)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JUSTIN
Last Name:DUBOSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2901 W KINNICKINNIC RIVER PKWY STE 309
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3660
Mailing Address - Country:US
Mailing Address - Phone:414-649-1292
Mailing Address - Fax:
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7884
Practice Address - Country:US
Practice Address - Phone:262-942-5600
Practice Address - Fax:262-948-7388
Is Sole Proprietor?:No
Enumeration Date:2016-02-20
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI673932083P0011X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100068480Medicaid