Provider Demographics
NPI:1902914484
Name:REVIS, RICHARD C (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:REVIS
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:PO BOX 2757
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92859-0757
Mailing Address - Country:US
Mailing Address - Phone:714-748-0332
Mailing Address - Fax:714-748-0547
Practice Address - Street 1:966 CASS ST
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-4539
Practice Address - Country:US
Practice Address - Phone:831-372-2169
Practice Address - Fax:831-372-6323
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60362207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A603620Medicaid
CA00A603620Medicaid
CA00A603620Medicare ID - Type Unspecified