Provider Demographics
NPI:1801489299
Name:REBOYA GONZALEZ, ROBERT WILL (IDC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILL
Last Name:REBOYA GONZALEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36421 FLOWER BASKET RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-8675
Mailing Address - Country:US
Mailing Address - Phone:562-304-0891
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE BLDG 14
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-7000
Practice Address - Country:US
Practice Address - Phone:619-532-7968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider