Provider Demographics
NPI:1124066394
Name:DE RUBEIS, MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DE RUBEIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16515 S 40TH ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0558
Mailing Address - Country:US
Mailing Address - Phone:480-706-2020
Mailing Address - Fax:480-759-0016
Practice Address - Street 1:16515 S 40TH ST
Practice Address - Street 2:SUITE 111
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0558
Practice Address - Country:US
Practice Address - Phone:480-706-2020
Practice Address - Fax:480-759-0016
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ0591152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU33237Medicare UPIN
AZZOD591Medicare PIN