Healthcare Provider Details

I. General information

NPI: 1285855130
Provider Name (Legal Business Name): REBONG PEDIATRIC MEDICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 N JACKSON AVE
SAN JOSE CA
95116-1918
US

IV. Provider business mailing address

145 N JACKSON AVE
SAN JOSE CA
95116-1918
US

V. Phone/Fax

Practice location:
  • Phone: 408-729-3232
  • Fax: 408-729-2165
Mailing address:
  • Phone: 408-729-3232
  • Fax: 408-729-2165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH P. REBONG
Title or Position: PRES.
Credential: M.D.
Phone: 408-729-3232