Provider Demographics
NPI:1396094827
Name:DUBOSE, KUNTA-ALI G
Entity type:Individual
Prefix:MR
First Name:KUNTA-ALI
Middle Name:G
Last Name:DUBOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9536 PRINCETON SQUARE BLVD S APT 2305
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8356
Mailing Address - Country:US
Mailing Address - Phone:904-781-0600
Mailing Address - Fax:904-781-0016
Practice Address - Street 1:2392 EDGEWOOD AVE N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1725
Practice Address - Country:US
Practice Address - Phone:904-781-0611
Practice Address - Fax:904-781-0016
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator