Provider Demographics
NPI:1609822808
Name:RUBIN, LARRY I
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:I
Last Name:RUBIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BRIGHTON RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1647
Mailing Address - Country:US
Mailing Address - Phone:973-777-7911
Mailing Address - Fax:973-777-5403
Practice Address - Street 1:6 BRIGHTON RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1647
Practice Address - Country:US
Practice Address - Phone:973-777-7911
Practice Address - Fax:973-777-5403
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA35903207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1647903Medicaid
NJD96967Medicare UPIN