Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | A76057 | CA |
N | 207ND0101X | MOHS-Micrographic Surgeon | A76057 | CA |
N | 207ND0900X | Dermatopathologist | A76057 | CA |
N | 207NP0225X | Pediatric Dermatologist | A76057 | CA |
N | 207NS0135X | Procedural Dermatology | A76057 | CA |
NPI | 1558452425 |
---|---|
Provider Name | Jeffrey Craig Rebish |
First Address | Upland, CA 91786-4085 |
Second Address | Upland, CA 91786-4085 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2006 |
Last Update Date | 15/10/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00A760571 | PTAN (01) | CA |
H75808 | (02) | CA |