Provider Demographics
NPI:1073391843
Name:RUBY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RUBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 YORK AVE APT 18N
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6342
Mailing Address - Country:US
Mailing Address - Phone:646-852-8625
Mailing Address - Fax:
Practice Address - Street 1:1233 YORK AVE APT 18N
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6342
Practice Address - Country:US
Practice Address - Phone:646-852-8625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP1213922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology