Provider Demographics
NPI:1689888968
Name:GABRIEL RUBANENKO INC A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GABRIEL RUBANENKO INC A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YETA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-965-5088
Mailing Address - Street 1:6200 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 908
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5801
Mailing Address - Country:US
Mailing Address - Phone:323-965-5088
Mailing Address - Fax:310-274-1040
Practice Address - Street 1:6200 WILSHIRE BLVD
Practice Address - Street 2:SUITE 910
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5801
Practice Address - Country:US
Practice Address - Phone:323-965-5088
Practice Address - Fax:310-274-1040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39466207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA39466OtherSTATE LICENSE #
CA00A394660Medicaid
CA00A394660Medicaid
CAA39466Medicare PIN
CAD73178Medicare UPIN