Healthcare Provider Details

I. General information

NPI: 1497943252
Provider Name (Legal Business Name): EDWARD RUBIN MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12134 VICTORY BLVD
NORTH HOLLYWOOD CA
91606-3205
US

IV. Provider business mailing address

12134 VICTORY BLVD
NORTH HOLLYWOOD CA
91606-3205
US

V. Phone/Fax

Practice location:
  • Phone: 818-749-7499
  • Fax: 818-761-2583
Mailing address:
  • Phone: 818-749-7499
  • Fax: 818-761-2583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG5507
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11460
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16862
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16393
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11867
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15767
License Number StateCA

VIII. Authorized Official

Name: EUGENE FUKUMOTO
Title or Position: MANAGER
Credential:
Phone: 626-299-4900