Healthcare Provider Details

I. General information

NPI: 1679565535
Provider Name (Legal Business Name): PAUL A ROUBIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 02/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER ROAD EGLIN AIRFORCE BASE
EGLIN AIRFORCE BASE FL
32542
US

IV. Provider business mailing address

1410 WEST MAIN STREET
WASHINGTON MO
63090
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-9279
  • Fax: 850-883-8400
Mailing address:
  • Phone: 573-576-8316
  • Fax: 636-432-1317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2008010696
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01436539
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: