Provider Demographics
NPI:1912941485
Name:REBURN, MICHAEL ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:REBURN
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 1:1310 LAS TABLAS RD STE 206
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-9747
Mailing Address - Country:US
Mailing Address - Phone:805-461-7080
Mailing Address - Fax:805-296-3566
Practice Address - Street 1:1310 LAS TABLAS RD STE 103
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9746
Practice Address - Country:US
Practice Address - Phone:805-434-0829
Practice Address - Fax:805-928-9588
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG1467432085R0202X
OK193652085R0202X
KS04-258292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100175670AMedicaid
KS100177170AMedicaid
KS100177170AMedicaid
OKP00202307Medicare PIN
KSP00415200Medicare PIN