Provider Demographics
NPI:1346242294
Name:REYBURN, DAVID KEVIN (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:KEVIN
Last Name:REYBURN
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 1:710 N STATE ROAD 25
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-9785
Mailing Address - Country:US
Mailing Address - Phone:574-223-8080
Mailing Address - Fax:574-223-8078
Practice Address - Street 1:1400 E 9TH ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-8931
Practice Address - Country:US
Practice Address - Phone:574-223-2020
Practice Address - Fax:574-223-5847
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042178208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200035290AMedicaid
IN270990EMedicare ID - Type Unspecified
IN200035290AMedicaid