Provider Demographics
NPI:1265062178
Name:BRUBAKER, JON ELLIOTT DALE (MD)
Entity type:Individual
Prefix:DR
First Name:JON ELLIOTT
Middle Name:DALE
Last Name:BRUBAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:310 W LOSEY ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225-5250
Mailing Address - Country:US
Mailing Address - Phone:618-256-9355
Mailing Address - Fax:618-256-7629
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-9355
Practice Address - Fax:618-256-7629
Is Sole Proprietor?:No
Enumeration Date:2020-01-20
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.165622208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist