Provider Demographics
NPI:1851344618
Name:RUBIN, KENNETH P (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:P
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 1:420 GRAND AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4152
Mailing Address - Country:US
Mailing Address - Phone:201-569-7044
Mailing Address - Fax:201-569-1999
Practice Address - Street 1:420 GRAND AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4152
Practice Address - Country:US
Practice Address - Phone:201-569-7044
Practice Address - Fax:201-569-1999
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04043000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1566300Medicaid
NJ56A411OtherEMPIRE HEALTH PLAN
NJOK2493OtherHEALTHNET
NJ0062833OtherGHI
NJ60833OtherAETNA US HEALTHCARE
NJBP377OtherOCFORD HEALTH PLAN
NJ60833OtherAETNA US HEALTHCARE
NJ565526BPCMedicare PIN