Provider Demographics
NPI:1083792501
Name:REVILLA, ANA RUTH (MD)
Entity Type:Individual
Prefix:DR
First Name:ANA
Middle Name:RUTH
Last Name:REVILLA
Suffix:
Gender:F
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 779
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-0779
Mailing Address - Country:US
Mailing Address - Phone:209-373-2800
Mailing Address - Fax:209-373-2873
Practice Address - Street 1:701 E CHANNEL ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2628
Practice Address - Country:US
Practice Address - Phone:209-944-4700
Practice Address - Fax:209-944-4727
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81029208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics