Provider Demographics
NPI:1194704643
Name:RUBANENKO, GABRIEL V (MD)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:V
Last Name:RUBANENKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 908
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5801
Mailing Address - Country:US
Mailing Address - Phone:323-965-5088
Mailing Address - Fax:310-274-1040
Practice Address - Street 1:6200 WILSHIRE BLVD
Practice Address - Street 2:SUITE 910
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5801
Practice Address - Country:US
Practice Address - Phone:323-965-5088
Practice Address - Fax:310-274-1040
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39466207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A394660Medicaid
CA00A394660Medicaid
CAWA39466FMedicare PIN