Provider Demographics
NPI:1093200115
Name:GREWAL, REVANT SINGH (MD)
Entity Type:Individual
Prefix:
First Name:REVANT
Middle Name:SINGH
Last Name:GREWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3414 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2714
Mailing Address - Country:US
Mailing Address - Phone:718-630-7942
Mailing Address - Fax:
Practice Address - Street 1:3414 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2714
Practice Address - Country:US
Practice Address - Phone:718-630-7942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-30
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072738207R00000X
NY312315207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine