Provider Demographics
NPI:1093743296
Name:RUBIO, ROBERTO
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:RUBIO
Suffix:
Gender:M
Credentials:
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 464
Mailing Address - Street 2:215 SOUTH PARRISH AVE.
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-0464
Mailing Address - Country:US
Mailing Address - Phone:229-896-6288
Mailing Address - Fax:229-896-1755
Practice Address - Street 1:215 S PARRISH AVE
Practice Address - Street 2:SUITE A.
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-3229
Practice Address - Country:US
Practice Address - Phone:229-896-6288
Practice Address - Fax:229-896-1755
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038084173000000X
SC89617208M00000X
FLME103608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF87768Medicare UPIN