Provider Demographics
NPI:1528406287
Name:MARIE ANSON-REBONG
Entity Type:Organization
Organization Name:MARIE ANSON-REBONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANSON-REBONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-729-3232
Mailing Address - Street 1:2350 MCKEE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1606
Mailing Address - Country:US
Mailing Address - Phone:408-729-3232
Mailing Address - Fax:408-729-3232
Practice Address - Street 1:2350 MCKEE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1606
Practice Address - Country:US
Practice Address - Phone:408-729-3232
Practice Address - Fax:408-729-3232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-04
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45814261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care