Provider Demographics
NPI:1154840767
Name:RUBY, RODGER (DO)
Entity Type:Individual
Prefix:
First Name:RODGER
Middle Name:
Last Name:RUBY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:MR
Other - First Name:RODGER
Other - Middle Name:RUBY
Other - Last Name:CAGAWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-490-1222
Mailing Address - Fax:
Practice Address - Street 1:3200 KEARNEY ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2299
Practice Address - Country:US
Practice Address - Phone:510-490-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A15987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine