Healthcare Provider Details

I. General information

NPI: 1255746368
Provider Name (Legal Business Name): MARK REBOLOS M.D. , F.A.C.O.G
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5645 MAIN ST DEPT OF
FLUSHING NY
11355-5045
US

IV. Provider business mailing address

5645 MAIN ST
FLUSHING NY
11355-5045
US

V. Phone/Fax

Practice location:
  • Phone: 718-670-2000
  • Fax:
Mailing address:
  • Phone: 718-630-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number298180
License Number StateNY
# 2
Primary TaxonomyN
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: