1265500508 NPI number — DR. JANE DREEBEN PH.D., L.A.D.C. I

Table of content: (NPI 1255081998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265500508 NPI number — DR. JANE DREEBEN PH.D., L.A.D.C. I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DREEBEN
Provider First Name:
JANE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., L.A.D.C. I
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265500508
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 516
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST TISBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02575-0516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-693-5523
Provider Business Mailing Address Fax Number:
508-696-8619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 CHURCH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VINEYARD HAVEN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-693-5523
Provider Business Practice Location Address Fax Number:
508-696-8619
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  6648 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TA0400X , with the licence number: 415 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: W05885 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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