Healthcare Provider Details

I. General information

NPI: 1528406287
Provider Name (Legal Business Name): MARIE ANSON-REBONG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 MCKEE RD SUITE 1
SAN JOSE CA
95116-1606
US

IV. Provider business mailing address

2350 MCKEE RD SUITE 1
SAN JOSE CA
95116-1606
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA45814
License Number StateCA

VIII. Authorized Official

Name: MARIE ANSON-REBONG
Title or Position: OWNER
Credential: MD
Phone: 408-729-3232