Healthcare Provider Details

I. General information

NPI: 1043261746
Provider Name (Legal Business Name): BHAVANA REBBA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BHAVANA JAKKA M.D.

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MAY ST SUITE F
EDISON NJ
08837-3266
US

IV. Provider business mailing address

45 HUNT DR
PISCATAWAY NJ
08854-6270
US

V. Phone/Fax

Practice location:
  • Phone: 732-738-6232
  • Fax:
Mailing address:
  • Phone: 732-463-0536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number25MA07822300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA07822300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: