Provider Demographics
NPI:1619073491
Name:RUBIO, EDMUNDO RAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUNDO
Middle Name:RAUL
Last Name:RUBIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 CRYSTAL SPRING AVE SW
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-2462
Mailing Address - Country:US
Mailing Address - Phone:540-985-8505
Mailing Address - Fax:540-344-3313
Practice Address - Street 1:2001 CRYSTAL SPRING AVE SW
Practice Address - Street 2:SUITE 205
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2462
Practice Address - Country:US
Practice Address - Phone:540-985-8505
Practice Address - Fax:540-344-3313
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17151207RC0200X, 207RP1001X
VA0101-243666207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124283Medicaid
MS290000149Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE
MS00124283Medicaid