Provider Demographics
NPI:1679606156
Name:RUBEN, SAMUEL MARK (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:MARK
Last Name:RUBEN
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 1:2176 KAIWIKI RD
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-9722
Mailing Address - Country:US
Mailing Address - Phone:808-430-2596
Mailing Address - Fax:808-934-9360
Practice Address - Street 1:900 LEILANI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-7512
Practice Address - Country:US
Practice Address - Phone:808-430-2596
Practice Address - Fax:808-934-9360
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD5759208D00000X
CAA358192083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03006790878OtherME#
OR084538Medicaid
CA03006790878OtherME#
CAA27916Medicare UPIN