Healthcare Provider Details

I. General information

NPI: 1609866953
Provider Name (Legal Business Name): GREGORY J RUBINO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 OAK PARK BLVD FL 3
LAKE CHARLES LA
70601-8990
US

IV. Provider business mailing address

PO BOX 122425 DEPT 2425
DALLAS TX
75312-0001
US

V. Phone/Fax

Practice location:
  • Phone: 337-494-4720
  • Fax: 337-494-2085
Mailing address:
  • Phone: 337-494-2921
  • Fax: 337-494-6523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD199953
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: