Provider Demographics
NPI:1891893020
Name:REBOLLEDO, MICHAEL A (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:REBOLLEDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 N DUNLAP ST
Mailing Address - Street 2:G145
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-4625
Mailing Address - Country:US
Mailing Address - Phone:901-287-5594
Mailing Address - Fax:901-287-6804
Practice Address - Street 1:848 ADAMS AVE
Practice Address - Street 2:L400
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2816
Practice Address - Country:US
Practice Address - Phone:901-287-7337
Practice Address - Fax:901-287-4646
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA528962080P0202X
TN541872080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A528960Medicaid
CAG66789Medicare UPIN