Provider Demographics
NPI:1457376998
Name:RUBY, SHIRLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:
Last Name:RUBY
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 1:605 LAMONT AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-2709
Mailing Address - Country:US
Mailing Address - Phone:718-439-3049
Mailing Address - Fax:718-439-3219
Practice Address - Street 1:5004 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-1814
Practice Address - Country:US
Practice Address - Phone:718-439-3049
Practice Address - Fax:718-439-3219
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115378208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00212708Medicaid
NYC11417Medicare UPIN