Provider Demographics
NPI:1235252289
Name:REBISH, SANDRA LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:LEE
Last Name:REBISH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:859 E FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4085
Practice Address - Country:US
Practice Address - Phone:909-981-8929
Practice Address - Fax:909-946-9740
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81296207ND0101X, 207N00000X, 207NS0135X, 207ND0900X, 207ND0101X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH88217Medicare UPIN
CAZZZ27252ZMedicare PIN