Provider Demographics
NPI:1891353785
Name:PORUDOMINSKY ROTSTAIN, RUBEN
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:
Last Name:PORUDOMINSKY ROTSTAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 QUEENS WAY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-3309
Mailing Address - Country:US
Mailing Address - Phone:561-900-4673
Mailing Address - Fax:
Practice Address - Street 1:4300 ALTON RD
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2948
Practice Address - Country:US
Practice Address - Phone:561-900-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program