Basic Information
| Provider Information | |||||||||
| NPI: | 1841355179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEJARNETTE | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | RUBIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUBIN | ||||||||
| OtherFirstName: | JUDITH | ||||||||
| OtherMiddleName: | PHYLLIS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | KAISER PERMANENTE MEDICARE ENROLLMENT | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018162424 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4920 CAMPBELL BLVD | ||||||||
| Address2: | |||||||||
| City: | NOTTINGHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212365916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109337600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101058716 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD038482 | DC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | D31652 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 406601440 | 05 | MD | MEDICAID |