Provider Demographics
NPI:1366961542
Name:ISUBIKALU, DOREEN LUBI
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:LUBI
Last Name:ISUBIKALU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8033 JOCELYN AVE S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016
Mailing Address - Country:US
Mailing Address - Phone:651-707-6130
Mailing Address - Fax:
Practice Address - Street 1:2330 SIOUX TRAIL NW
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372
Practice Address - Country:US
Practice Address - Phone:952-496-6150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5160207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine