Basic Information
| Provider Information | |||||||||
| NPI: | 1679787048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUTA | ||||||||
| FirstName: | MARIAN | ||||||||
| MiddleName: | CUBA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUTA | ||||||||
| OtherFirstName: | MARIAN | ||||||||
| OtherMiddleName: | CUBA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6278 MONTROSE RD | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2407509966 | ||||||||
| FaxNumber: | 3012992389 | ||||||||
| Practice Location | |||||||||
| Address1: | 6278 MONTROSE RD | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2407509966 | ||||||||
| FaxNumber: | 3012992382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 18214 | MD | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | KH49AD | 01 | MD | BCBS MD | OTHER | 565601000 | 05 | MD | MEDICAID | F8297 | 01 | MD | NATIONAL CAPITAL | OTHER |