Provider Demographics
NPI:1831108729
Name:REBOLLAR, MIGUEL (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:REBOLLAR
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 1:1435 W 49 PL SUITE 201
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012
Mailing Address - Country:US
Mailing Address - Phone:305-828-4155
Mailing Address - Fax:305-828-9339
Practice Address - Street 1:1435 W 49 PL SUITE 201
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012
Practice Address - Country:US
Practice Address - Phone:305-828-4155
Practice Address - Fax:305-828-9339
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51316207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE47455Medicare UPIN