Provider Demographics
NPI:1639210974
Name:JONATHAN C REBOTON MD LTD
Entity Type:Organization
Organization Name:JONATHAN C REBOTON MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:REBOTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-307-8618
Mailing Address - Street 1:1905 MCDANIEL ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-7169
Mailing Address - Country:US
Mailing Address - Phone:702-307-8618
Mailing Address - Fax:702-307-6819
Practice Address - Street 1:1905 MCDANIEL ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7169
Practice Address - Country:US
Practice Address - Phone:702-307-8618
Practice Address - Fax:702-307-6819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018170Medicaid
NVV34447Medicare ID - Type Unspecified
NV002018170Medicaid