Provider Demographics
NPI:1053385195
Name:BRUBAKER, LINDA (MD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:BRUBAKER
Suffix:
Gender:F
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 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:858-249-6749
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:(RUSSO ENT., RM. 1016)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-8563
Practice Address - Fax:708-216-2275
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36072594207V00000X, 2088F0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088F0040XAllopathic & Osteopathic PhysiciansUrologyUrogynecology and Reconstructive Pelvic Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL572070Medicare ID - Type Unspecified
E64508Medicare UPIN