Provider Demographics
NPI:1992906382
Name:KUBEK, EDWARD WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WILLIAM
Last Name:KUBEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:1373 E SR 62
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250
Practice Address - Country:US
Practice Address - Phone:812-801-0840
Practice Address - Fax:812-801-0024
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01078254A208600000X, 208200000X, 208200000X
MI4301089997390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5778586OtherUHC
IN226996OtherSIHO
KY7100469740Medicaid
KY50126138OtherKY PASSPORT
IN1075366OtherANTHEM
IN4384232OtherAETNA
IN300001450Medicaid