Provider Demographics
NPI:1346236205
Name:RUBIN, JACK E (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:RUBIN
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:PO BOX 260458
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91426-0458
Mailing Address - Country:US
Mailing Address - Phone:818-784-4201
Mailing Address - Fax:818-784-4206
Practice Address - Street 1:575 E HARDY ST
Practice Address - Street 2:SUITE 322
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4036
Practice Address - Country:US
Practice Address - Phone:310-671-0488
Practice Address - Fax:310-671-7618
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG060194207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G60194Medicaid
CA00G60194Medicaid
G060194Medicare ID - Type Unspecified