Provider Demographics
NPI:1558452425
Name:REBISH, JEFFREY CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CRAIG
Last Name:REBISH
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 1:859 E FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4085
Mailing Address - Country:US
Mailing Address - Phone:909-981-8929
Mailing Address - Fax:909-946-9740
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?:No
Enumeration Date:2006-09-27
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76057207N00000X, 207NS0135X, 207ND0900X, 207ND0101X, 207NP0225X
CAS76057207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A760571OtherPTAN
CA00A760571OtherPTAN
CAZZZ27252ZMedicare ID - Type Unspecified