Provider Demographics
NPI:1124014196
Name:RUILOBA, ELIAS OMAR (MD)
Entity Type:Individual
Prefix:MR
First Name:ELIAS
Middle Name:OMAR
Last Name:RUILOBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:E
Other - Middle Name:OMAR
Other - Last Name:RUILOBA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1743 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0927
Mailing Address - Country:US
Mailing Address - Phone:928-757-8111
Mailing Address - Fax:928-757-3256
Practice Address - Street 1:2002 N STOCKTON HILL RD
Practice Address - Street 2:#104
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4698
Practice Address - Country:US
Practice Address - Phone:928-718-4800
Practice Address - Fax:928-757-3256
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ254582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
I10530Medicare UPIN
Z60036Medicare ID - Type Unspecified