Provider Demographics
NPI:1225109770
Name:CLARK, MARY ELIZABETH REVILLA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY ELIZABETH
Middle Name:REVILLA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2333 BUCHANAN ST
Mailing Address - Street 2:SUITE 5823
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-1925
Mailing Address - Country:US
Mailing Address - Phone:415-644-5752
Mailing Address - Fax:
Practice Address - Street 1:2333 BUCHANAN ST
Practice Address - Street 2:SUITE 5823
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-1925
Practice Address - Country:US
Practice Address - Phone:415-644-5752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA98304207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA98304OtherCALIFORNIA STATE LICENSE
HIMD-12890OtherHAWAII MEDICAL LICENSE
CAA98304OtherCALIFORNIA STATE LICENSE