Provider Demographics
NPI:1710063920
Name:RUBIN, ELISSA HOPE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:HOPE
Last Name:RUBIN
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:PO BOX 1720
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-0902
Mailing Address - Country:US
Mailing Address - Phone:516-216-5910
Mailing Address - Fax:516-216-5907
Practice Address - Street 1:77 JERICHO TPKE
Practice Address - Street 2:SUITE 175
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-2984
Practice Address - Country:US
Practice Address - Phone:516-216-5910
Practice Address - Fax:516-216-5907
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230355208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02909520Medicaid