Basic Information
Provider Information | |||||||||
NPI: | 1245324359 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUBIN | ||||||||
FirstName: | JONATHON | ||||||||
MiddleName: | AARON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 STEWART AVE | ||||||||
Address2: |   | ||||||||
City: | GARDEN CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 115304721 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 700 STEWART AVE | ||||||||
Address2: |   | ||||||||
City: | GARDEN CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 115304721 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5166631220 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2006 | ||||||||
LastUpdateDate: | 04/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 231751 | NY | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 4301091453 | MI | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0102X | 231751 | NY | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0129X | 046504 | CT | N |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 231751 | NY | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 02818091 | 05 | NY |   | MEDICAID |