Healthcare Provider Details

I. General information

NPI: 1851345284
Provider Name (Legal Business Name): STEPHEN A RUBENDALL JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 US HIGHWAY 19 NORTH
CAMILLA GA
31730-1410
US

IV. Provider business mailing address

259 US HIGHWAY 19 NORTH
CAMILLA GA
31730-1410
US

V. Phone/Fax

Practice location:
  • Phone: 229-336-1949
  • Fax: 229-336-1436
Mailing address:
  • Phone: 229-336-1949
  • Fax: 229-336-1436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number057320
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: