Provider Demographics
NPI:1720125131
Name:RUBIN, JEFFREY W (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
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 1:240 HERITAGE WALK
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3875
Mailing Address - Country:US
Mailing Address - Phone:770-516-7880
Mailing Address - Fax:770-516-7870
Practice Address - Street 1:240 HERITAGE WALK
Practice Address - Street 2:SUITE 101
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3875
Practice Address - Country:US
Practice Address - Phone:770-516-7880
Practice Address - Fax:770-516-7870
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030873207L00000X, 207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I720008Medicare PIN
GAE98399Medicare UPIN