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: 05/31/2024
Certification Date: 05/24/2024
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 STREET CLINIC TOWER A7D
LOS ANGELES CA
90033
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 Code207ZN0500X
TaxonomyNeuropathology Physician
License NumberA195356
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License NumberA195356
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA195356
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberA195356
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: