Healthcare Provider Details

I. General information

NPI: 1699478511
Provider Name (Legal Business Name): RUBAB MIAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WAVERLY AVE
PATCHOGUE NY
11772-1555
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-6300
  • Fax: 631-444-6327
Mailing address:
  • Phone: 631-444-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number342824-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: