Basic Information
| Provider Information | |||||||||
| NPI: | 1902914484 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REVIS | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2757 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928590757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147480332 | ||||||||
| FaxNumber: | 7147480547 | ||||||||
| Practice Location | |||||||||
| Address1: | 966 CASS ST | ||||||||
| Address2: | |||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939404539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313722169 | ||||||||
| FaxNumber: | 8313726323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A60362 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A603620 | 05 | CA | MEDICAID |