Provider Demographics
NPI:1588612964
Name:RUBENZIK, RANDI E (MD)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:E
Last Name:RUBENZIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11130 N TATUM BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1630
Mailing Address - Country:US
Mailing Address - Phone:602-494-1817
Mailing Address - Fax:602-494-7103
Practice Address - Street 1:11130 N TATUM BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1630
Practice Address - Country:US
Practice Address - Phone:602-494-1817
Practice Address - Fax:602-494-7103
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26180207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z5232OtherHEALTH NET
AZ542557Medicaid
AZ070013969OtherRAILROAD MEDICARE
AZ99S007000006OtherMEDISUN
AZ1588612964OtherAHCCCS
AZ1995262OtherUNITED HEALTHCARE
AZAZ0869290OtherBLUE CROSS BLUE SHIELD
AZ7096132OtherAETNA
AZ188961600OtherDEPT OF LABOR WORK COMP
AZ1995262OtherUNITED HEALTHCARE
AZ542557Medicaid
AZAZ0869290OtherBLUE CROSS BLUE SHIELD