Basic Information
| Provider Information | |||||||||
| NPI: | 1861682940 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKERYWALA | ||||||||
| FirstName: | RUBINA | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 807 CHILDRENS WAY | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026973694 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 CHILDRENS WAY | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026973694 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2007 | ||||||||
| LastUpdateDate: | 07/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | ME109578 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 003504400 | 05 | FL | MEDICAID |