Healthcare Provider Details

I. General information

NPI: 1972501302
Provider Name (Legal Business Name): MATTHEW WILLIAM RUBLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CONWELL ST
PROVINCETOWN MA
02657-1548
US

IV. Provider business mailing address

PO BOX 964
TRURO MA
02666-0964
US

V. Phone/Fax

Practice location:
  • Phone: 508-487-1459
  • Fax: 508-349-0966
Mailing address:
  • Phone: 508-349-9661
  • Fax: 508-349-0966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number208742
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: