Provider Demographics
NPI:1194749341
Name:RUBIN, MARK LESLIE (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LESLIE
Last Name:RUBIN
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:PO BOX 11417
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-0024
Mailing Address - Country:US
Mailing Address - Phone:480-284-7304
Mailing Address - Fax:480-284-7616
Practice Address - Street 1:2020 S. MCCLINTOCK DR.#105
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282
Practice Address - Country:US
Practice Address - Phone:480-284-7304
Practice Address - Fax:480-284-7616
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ188012084P0005X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ431982Medicaid
1194749341OtherNPI
1194749341OtherNPI
AR1261457OtherDEA