Provider Demographics
NPI:1730813940
Name:REBELLO, ANTHONY DAVID III (LDO)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:DAVID
Last Name:REBELLO
Suffix:III
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-5111
Mailing Address - Country:US
Mailing Address - Phone:401-251-2309
Mailing Address - Fax:401-223-5846
Practice Address - Street 1:1 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-5111
Practice Address - Country:US
Practice Address - Phone:401-251-2309
Practice Address - Fax:401-223-5846
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI339156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician