Provider Demographics
NPI:1558553313
Name:DE RUBERTIS, BRIAN G (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:G
Last Name:DE RUBERTIS
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 1:525 E 68TH ST # 197
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:646-962-8450
Mailing Address - Fax:646-962-0323
Practice Address - Street 1:525 E 68TH ST # F835-A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:646-962-8450
Practice Address - Fax:646-962-0323
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY218073012086S0129X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1558553313Medicaid
CAOTH000Medicare UPIN
CAWA100623AMedicare PIN