Provider Demographics
NPI:1841355179
Name:DEJARNETTE, JUDITH RUBIN (MD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:RUBIN
Last Name:DEJARNETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:PHYLLIS
Other - Last Name:RUBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:4920 CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-5916
Practice Address - Country:US
Practice Address - Phone:410-933-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058716208000000X
DCMD038482208000000X
MDD31652208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406601440Medicaid
MD406601440Medicaid
B70691Medicare UPIN