Basic Information
| Provider Information | |||||||||
| NPI: | 1124014196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUILOBA | ||||||||
| FirstName: | ELIAS | ||||||||
| MiddleName: | OMAR | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | RUILOBA | ||||||||
| OtherFirstName: | E | ||||||||
| OtherMiddleName: | OMAR | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1743 SYCAMORE AVE | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864090927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287578111 | ||||||||
| FaxNumber: | 9287573256 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 N STOCKTON HILL RD | ||||||||
| Address2: | #104 | ||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864014698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287184800 | ||||||||
| FaxNumber: | 9287573256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 25458 | AZ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.