Provider Demographics
NPI:1841290368
Name:CLARK-RUBIN, LORNA JAYNE (MD)
Entity type:Individual
Prefix:
First Name:LORNA
Middle Name:JAYNE
Last Name:CLARK-RUBIN
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 1:11 HAMMOND LN
Mailing Address - Street 2:STE A
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2003
Mailing Address - Country:US
Mailing Address - Phone:518-561-0063
Mailing Address - Fax:518-561-0947
Practice Address - Street 1:11 HAMMOND LN
Practice Address - Street 2:STE A
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2003
Practice Address - Country:US
Practice Address - Phone:518-561-0063
Practice Address - Fax:518-561-0947
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183078-12084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY137849OtherVALUEOPTIONS
3194595OtherGHI
NY01201207Medicaid
NY209121OtherMVP
NY000490037001OtherBLUESHIELD OF NORTHEASTERN NY
NY52223CMedicare PIN
NY01201207Medicaid