Provider Demographics
NPI:1184629057
Name:MIRBEGIAN, ROUBEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROUBEN
Middle Name:
Last Name:MIRBEGIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 EMERSON ST
Mailing Address - Street 2:STE B
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9529
Mailing Address - Country:US
Mailing Address - Phone:707-995-2180
Mailing Address - Fax:707-995-2114
Practice Address - Street 1:3400 EMERSON ST
Practice Address - Street 2:STE B
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9529
Practice Address - Country:US
Practice Address - Phone:707-995-2180
Practice Address - Fax:707-995-2114
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38350207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A383500Medicaid
P00186016OtherMEDICARE RAILROAD #
P00186016OtherMEDICARE RAILROAD #
CA00A383500Medicaid