Active NPI
Justin F Bubolz, M.D.
- Pediatrics Physician
- Hannibal, MO
National Provider Identifier
1962481630
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- R2H02
- Practice address
- 100 Medical Dr
Hannibal, MO 63401-6877 - Phone
- (573) 231-3102
- Fax
- (573) 231-3723
- NPI assigned
- Jan 11, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | R2H02 | MO | Primary |
Addresses
Primary practice location
100 Medical Dr
Hannibal, MO 63401-6877
Mailing address
100 Medical Dr
Hannibal, MO 63401-6877
Phone (573) 231-3102
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 209722503 | Medicaid | MO |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| R2H02 | MO | MD | Pediatrics Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1136937600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1633651200000",
"number": "1962481630",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "100 MEDICAL DR",
"city": "HANNIBAL",
"state": "MO",
"postal_code": "634016877",
"telephone_number": "573-231-3102",
"fax_number": "573-231-3723"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "100 MEDICAL DR",
"city": "HANNIBAL",
"state": "MO",
"postal_code": "634016877",
"telephone_number": "573-231-3102",
"fax_number": "573-231-3723"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BUBOLZ",
"first_name": "JUSTIN",
"middle_name": "F",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-01-11",
"last_updated": "2021-10-08",
"certification_date": "2021-10-08",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "MO",
"license": "R2H02",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "209722503",
"state": "MO"
}
],
"endpoints": [],
"other_names": []
}Other providers in Hannibal, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 8, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.