Provider Demographics
NPI:1306226121
Name:REBELLO, CLINTON (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:
Last Name:REBELLO
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 1:3458 NEELY RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08641-5312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3458 NEELY RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08641-5312
Practice Address - Country:US
Practice Address - Phone:609-754-9713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-06
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
IN01078834A207Q00000X, 208D00000X
NJ25MA11691000207Q00000X
AK201003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA207Q00000XOtherFAMILY MEDICINE