Provider Demographics
NPI:1205857240
Name:RUBERTE, MARIO E (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:E
Last Name:RUBERTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARIO
Other - Middle Name:E
Other - Last Name:RUBERTE SANCHEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR STE 1C
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-312-3330
Practice Address - Fax:321-727-8761
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL90303OtherBCBS
FL5219860OtherCIGNA
FL7584993OtherAETNA
FLP01164196OtherRR MEDICARE
FL101164800Medicaid
FLP01164196OtherRR MEDICARE