Provider Demographics
NPI:1902893373
Name:BUBAK, VIRGINIA (PT CERT MDT MTC)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:BUBAK
Suffix:
Gender:F
Credentials:PT CERT MDT MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 FRONT STREET
Mailing Address - Street 2:PO BOX 1464
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545
Mailing Address - Country:US
Mailing Address - Phone:845-677-5021
Mailing Address - Fax:845-677-3117
Practice Address - Street 1:2 FRONT STREET
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:NY
Practice Address - Zip Code:12545
Practice Address - Country:US
Practice Address - Phone:845-677-5021
Practice Address - Fax:845-677-3117
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011927225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q01151Medicare ID - Type Unspecified
P20920Medicare UPIN