Provider Demographics
NPI:1619904174
Name:RUBIN, JACK D (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:RUBIN
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 1:161 WEST 61ST STREET APT. 18B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10023
Mailing Address - Country:US
Mailing Address - Phone:732-846-2777
Mailing Address - Fax:732-828-1950
Practice Address - Street 1:161 WEST 61ST STREET, APT. 18B
Practice Address - Street 2:
Practice Address - City:NEW YORK CITY
Practice Address - State:NY
Practice Address - Zip Code:10023
Practice Address - Country:US
Practice Address - Phone:732-846-2777
Practice Address - Fax:732-828-1950
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086041207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ143033A3DMedicare PIN