Provider Demographics
NPI:1013029503
Name:REVAK, DAVID M (D O)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:REVAK
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 CHAPEL VIEW DR
Mailing Address - Street 2:P. O. BOX 119
Mailing Address - City:REINHOLDS
Mailing Address - State:PA
Mailing Address - Zip Code:17569-0119
Mailing Address - Country:US
Mailing Address - Phone:717-336-5824
Mailing Address - Fax:717-336-5401
Practice Address - Street 1:171 CHAPEL VIEW DR
Practice Address - Street 2:
Practice Address - City:REINHOLDS
Practice Address - State:PA
Practice Address - Zip Code:17569-0119
Practice Address - Country:US
Practice Address - Phone:717-336-5824
Practice Address - Fax:717-336-5401
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005938L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
542115OtherBLUE SHIELD
50051246OtherCAPITAL BLUE
P005066OtherGATEWAY
4641800OtherAETNA
P00262037OtherRAILROAD MEDICARE
PA0011813120004Medicaid
5838474OtherUSH/HMO
P005066OtherGATEWAY
PAE54261Medicare UPIN