Healthcare Provider Details

I. General information

NPI: 1962716373
Provider Name (Legal Business Name): ELYSE RUBENSTEIN MD, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 16TH ST
SANTA MONICA CA
90404-1804
US

IV. Provider business mailing address

2980 N BEVERLY GLEN CIR STE 301
LOS ANGELES CA
90077-1726
US

V. Phone/Fax

Practice location:
  • Phone: 310-256-2425
  • Fax:
Mailing address:
  • Phone: 310-474-9809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: ELYSE RUBENSTEIN
Title or Position: PRESIDENT
Credential: MD
Phone: 310-256-2425