Provider Demographics
NPI:1164584215
Name:REVOLINSKI, JASON PAUL (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PAUL
Last Name:REVOLINSKI
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 1:820 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3483
Mailing Address - Country:US
Mailing Address - Phone:920-731-5811
Mailing Address - Fax:
Practice Address - Street 1:W180N8000 TOWN HALL RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-4002
Practice Address - Country:US
Practice Address - Phone:262-532-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50161-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine