Provider Demographics
NPI:1700882479
Name:RUBIN, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
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:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-1127
Mailing Address - Country:US
Mailing Address - Phone:562-596-1667
Mailing Address - Fax:562-596-7514
Practice Address - Street 1:10941 BLOOMFIELD ST
Practice Address - Street 2:SUITE A
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2530
Practice Address - Country:US
Practice Address - Phone:562-596-1667
Practice Address - Fax:562-596-7514
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70182207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G701820Medicaid
CA00G701820Medicaid
B29954Medicare UPIN