Basic Information
| Provider Information | |||||||||
| NPI: | 1962620294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AREVALO | ||||||||
| FirstName: | IRACEMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 18 FOX RUN DR | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434208562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5672012213 | ||||||||
| FaxNumber: | 4193348546 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 S TAFT AVE | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434203200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193346679 | ||||||||
| FaxNumber: | 4193346690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 04/14/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0208X | 35089621 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | 282NR1301X | 35. 089621 | OH | N | Hospitals | General Acute Care Hospital | Rural |
No ID Information.