Provider Demographics
NPI:1225087349
Name:REVELLE, BONNIE CAUKINS (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:CAUKINS
Last Name:REVELLE
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 1:811 REDGATE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1515
Mailing Address - Country:US
Mailing Address - Phone:757-668-7007
Mailing Address - Fax:757-668-8658
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-7456
Practice Address - Fax:757-668-9255
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240729208000000X, 2080N0001X
NC27288208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8971295Medicaid
NC71295OtherBLUE CROSS BLUE SHIELD
NC890160MMedicaid
NC890160MMedicaid