Healthcare Provider Details

I. General information

NPI: 1851978175
Provider Name (Legal Business Name): GREGORY JEBIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GREGORY JEBIAN BASTOURI MD

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-355-1122
  • Fax:
Mailing address:
  • Phone: 305-355-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number12985853-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: