Provider Demographics
NPI:1366583064
Name:RUSSELL F GUBA JR MD
Entity type:Organization
Organization Name:RUSSELL F GUBA JR MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:F
Authorized Official - Last Name:GUBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-568-2020
Mailing Address - Street 1:220 KNICKERBOCKER RD
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-1827
Mailing Address - Country:US
Mailing Address - Phone:201-568-2020
Mailing Address - Fax:201-568-4213
Practice Address - Street 1:220 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626-1827
Practice Address - Country:US
Practice Address - Phone:201-568-2020
Practice Address - Fax:201-568-4213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA43638207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0K4573OtherHEALTHNET
NJP1680384OtherOXFORD
NJP1680384OtherOXFORD
NJC56653Medicare UPIN