Healthcare Provider Details

I. General information

NPI: 1720279573
Provider Name (Legal Business Name): DMITRY SERGEI RUBAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 OGDEN AVE SUITE 300
AURORA IL
60504-7206
US

IV. Provider business mailing address

2040 OGDEN AVE STE 300
AURORA IL
60504-7205
US

V. Phone/Fax

Practice location:
  • Phone: 630-978-6770
  • Fax: 630-978-6773
Mailing address:
  • Phone: 630-978-6770
  • Fax: 630-978-6773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number036.119486
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: