Basic Information
| Provider Information | |||||||||
| NPI: | 1194882571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REVAN | ||||||||
| FirstName: | VIDYASHANKAR | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REVANNASIDDAPPA | ||||||||
| OtherFirstName: | VIDYASHANKAR | ||||||||
| OtherMiddleName: | B | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9800 SHELBYVILLE RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402232992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024298585 | ||||||||
| FaxNumber: | 5027530889 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 FAIRWAY DR | ||||||||
| Address2: | SUITE # 2 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451778756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376559179 | ||||||||
| FaxNumber: | 9376559139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 35080833 | OH | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 2321660 | 05 | OH | MEDICAID |