Provider Demographics
NPI:1083677314
Name:RUBIN, TOD (DO)
Entity Type:Individual
Prefix:
First Name:TOD
Middle Name:
Last Name:RUBIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-1002
Mailing Address - Country:US
Mailing Address - Phone:770-732-3649
Mailing Address - Fax:770-732-3648
Practice Address - Street 1:4441 ATLANTA RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6406
Practice Address - Country:US
Practice Address - Phone:770-702-1806
Practice Address - Fax:770-693-0810
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040529207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000705658AMedicaid
GA000705658AMedicaid
F60324Medicare UPIN