Healthcare Provider Details

I. General information

NPI: 1558452425
Provider Name (Legal Business Name): JEFFREY CRAIG REBISH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 E FOOTHILL BLVD STE B
UPLAND CA
91786-4085
US

IV. Provider business mailing address

859 E FOOTHILL BLVD STE B
UPLAND CA
91786-4085
US

V. Phone/Fax

Practice location:
  • Phone: 909-981-8929
  • Fax: 909-946-9740
Mailing address:
  • Phone: 909-981-8929
  • Fax: 909-946-9740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA76057
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License NumberS76057
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA76057
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberA76057
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA76057
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberA76057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: