Provider Demographics
NPI:1366573453
Name:HRUBY, RAYMOND JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:JOHN
Last Name:HRUBY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11115 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-1806
Mailing Address - Country:US
Mailing Address - Phone:909-466-8332
Mailing Address - Fax:
Practice Address - Street 1:309 E 2ND ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-1854
Practice Address - Country:US
Practice Address - Phone:909-469-5279
Practice Address - Fax:909-469-5289
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4620204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA93587Medicare UPIN