=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194749341
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK LESLIE RUBIN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 S. MCCLINTOCK DR.#105
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-284-7304
-----------------------------------------------------
Fax | 480-284-7616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 11417
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85284-0024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-284-7304
-----------------------------------------------------
Fax | 480-284-7616
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0005X
-----------------------------------------------------
Taxonomy Name | Neurodevelopmental Disabilities Physician
-----------------------------------------------------
License Number | 18801
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 18801
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 18801
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------