Provider Demographics
NPI:1841418522
Name:SEBASTIAN, REY ANGIOLO B (RPT)
Entity Type:Individual
Prefix:MR
First Name:REY ANGIOLO
Middle Name:B
Last Name:SEBASTIAN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 W KEM RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-9258
Mailing Address - Country:US
Mailing Address - Phone:765-384-4103
Mailing Address - Fax:
Practice Address - Street 1:729 W 35TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4215
Practice Address - Country:US
Practice Address - Phone:765-674-3371
Practice Address - Fax:765-677-5411
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000352295OtherANTHEM