Provider Demographics
NPI:1265691810
Name:REYBURN, BRENT STEVEN (DO)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:STEVEN
Last Name:REYBURN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5430 FREDERICKSBURG RD STE 508
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3561
Mailing Address - Country:US
Mailing Address - Phone:210-541-8281
Mailing Address - Fax:210-541-9123
Practice Address - Street 1:5430 FREDERICKSBURG RD STE 508
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3561
Practice Address - Country:US
Practice Address - Phone:210-541-8281
Practice Address - Fax:210-541-9123
Is Sole Proprietor?:No
Enumeration Date:2008-06-07
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.0101362080N0001X
TXP87222080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX334569601Medicaid
OH0080895Medicaid
TX334569601Medicaid