Healthcare Provider Details

I. General information

NPI: 1982817193
Provider Name (Legal Business Name): JACK RUBIN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 04/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11406 SAN JOSE BLVD STE 1
JACKSONVILLE FL
32223-7963
US

IV. Provider business mailing address

11406 SAN JOSE BLVD STE 1
JACKSONVILLE FL
32223-7963
US

V. Phone/Fax

Practice location:
  • Phone: 904-260-3839
  • Fax: 904-260-7879
Mailing address:
  • Phone: 904-260-3839
  • Fax: 904-260-7879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC1114
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: