Provider Demographics
NPI:1194009340
Name:REVOLUS, TANIA (MD)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:REVOLUS
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 1:1510 HAWKINS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1815
Mailing Address - Country:US
Mailing Address - Phone:516-428-7626
Mailing Address - Fax:
Practice Address - Street 1:2201 HEMPSTEAD TURNPIKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554
Practice Address - Country:US
Practice Address - Phone:516-572-6255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY279585207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology