Provider Demographics
NPI:1982677761
Name:RUBIN, GERRY (MD)
Entity type:Individual
Prefix:
First Name:GERRY
Middle Name:
Last Name:RUBIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 112 BLDG 4
Mailing Address - Street 2:SUITE101
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3456
Mailing Address - Country:US
Mailing Address - Phone:631-574-8354
Mailing Address - Fax:631-509-6559
Practice Address - Street 1:180 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8427
Practice Address - Country:US
Practice Address - Phone:631-751-3000
Practice Address - Fax:631-675-2001
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY177178207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02023150Medicaid
NY02023150Medicaid
NY14B211Medicare UPIN