Healthcare Provider Details

I. General information

NPI: 1215490859
Provider Name (Legal Business Name): RYAN W REBBE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N. STATE STREET CLINIC TOWER A7D
LOS ANGELES CA
90033
US

IV. Provider business mailing address

1100 N STATE ST
LOS ANGELES CA
90033-5000
US

V. Phone/Fax

Practice location:
  • Phone: 323-409-6931
  • Fax:
Mailing address:
  • Phone: 323-409-6931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License NumberDR.0078328
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License NumberA195356
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA195356
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberDR.0078328
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License NumberA195356
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: