Provider Demographics
NPI:1497943252
Name:EDWARD RUBIN MD
Entity Type:Organization
Organization Name:EDWARD RUBIN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:FUKUMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-299-4900
Mailing Address - Street 1:12134 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3205
Mailing Address - Country:US
Mailing Address - Phone:818-749-7499
Mailing Address - Fax:818-761-2583
Practice Address - Street 1:12134 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3205
Practice Address - Country:US
Practice Address - Phone:818-749-7499
Practice Address - Fax:818-761-2583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG5507207Q00000X
CAPA11460363A00000X
CAPA16862363A00000X
CAPA16393363A00000X
CAPA11867363A00000X
CAPA15767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16393Medicare PIN
CAPA16862Medicare PIN
CAG5507Medicare PIN
CAPA15767Medicare PIN
CAPA15248Medicare PIN
CAC46659Medicare UPIN
CAPA11460Medicare PIN
CAPA11867Medicare PIN
CAW16378Medicare PIN