Provider Demographics
NPI:1831269083
Name:REUBEN, JEFFERY M
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:M
Last Name:REUBEN
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:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:PORT ROYAL
Mailing Address - State:SC
Mailing Address - Zip Code:29935-0670
Mailing Address - Country:US
Mailing Address - Phone:843-379-7746
Mailing Address - Fax:843-522-1275
Practice Address - Street 1:40 OKATIE CTR BLVD STE 205
Practice Address - Street 2:
Practice Address - City:OKATIE
Practice Address - State:SC
Practice Address - Zip Code:29909-7511
Practice Address - Country:US
Practice Address - Phone:843-379-7746
Practice Address - Fax:843-522-1275
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21737174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT59460Medicaid
SCT59460Medicaid
SCH00882Medicare UPIN