Healthcare Provider Details

I. General information

NPI: 1639438088
Provider Name (Legal Business Name): ISIDORE DANIEL BENRUBI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

PO BOX 44008
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-383-1037
  • Fax:
Mailing address:
  • Phone: 904-244-3660
  • Fax: 904-244-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMD457186
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberME141541
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: