Provider Demographics
NPI:1114319191
Name:NOHRA REVILLA, DANIEL JESUS (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JESUS
Last Name:NOHRA REVILLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:DANIEL
Other - Middle Name:JESUS
Other - Last Name:NOHRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:32 W GORE ST FL 3
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1134
Mailing Address - Country:US
Mailing Address - Phone:407-352-5434
Mailing Address - Fax:407-345-9765
Practice Address - Street 1:32 W GORE ST FL 3
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1134
Practice Address - Country:US
Practice Address - Phone:407-352-5434
Practice Address - Fax:407-345-9765
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS157412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105776200Medicaid