Healthcare Provider Details

I. General information

NPI: 1144416348
Provider Name (Legal Business Name): JACK RUBIN M D A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 ATLANTIC AVE SUITE 915
LONG BEACH CA
90813-3408
US

IV. Provider business mailing address

PO BOX 1127
LOS ALAMITOS CA
90720-1127
US

V. Phone/Fax

Practice location:
  • Phone: 562-596-1667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: JACK RUBIN
Title or Position: OWNER
Credential: MD
Phone: 562-299-5239