Healthcare Provider Details

I. General information

NPI: 1205819661
Provider Name (Legal Business Name): PAMELA MARIE RUBNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELA MARIE DESELM MD

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 10/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S. MCCASLIN BLVD #103
LOUISVILLE CO
80027
US

IV. Provider business mailing address

400 S. MCCASLIN BLVD. #103
LOUISVILLE CO
80027
US

V. Phone/Fax

Practice location:
  • Phone: 303-666-7337
  • Fax:
Mailing address:
  • Phone: 303-666-7337
  • Fax: 303-666-7379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number54123901205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number45172
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD150351
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0055858
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: