Basic Information
| Provider Information | |||||||||
| NPI: | 1255746368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REBOLOS | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5645 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186307000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5645 MAIN ST DEPT OF | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186702000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2014 | ||||||||
| LastUpdateDate: | 07/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 298180 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.