Provider Demographics
NPI:1467490235
Name:RUBERTUS, MARK TAGUE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TAGUE
Last Name:RUBERTUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1127 GEORGE NIGH EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501
Mailing Address - Country:US
Mailing Address - Phone:918-423-8400
Mailing Address - Fax:918-423-0033
Practice Address - Street 1:1127 S GEORGE NIGH EXPY
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-7143
Practice Address - Country:US
Practice Address - Phone:918-423-8400
Practice Address - Fax:918-423-0033
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK25954207Q00000X
NC2009-00664207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA16690Medicare UPIN