Provider Demographics
NPI:1235236902
Name:REVA, JUDITH A (DO)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:REVA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 SAN PEDRO AVE STE 412
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2009
Mailing Address - Country:US
Mailing Address - Phone:210-281-8669
Mailing Address - Fax:210-314-5044
Practice Address - Street 1:6520 N PRESIDENT GEORGE BUSH HWY STE 100
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75044-3925
Practice Address - Country:US
Practice Address - Phone:972-532-9967
Practice Address - Fax:210-314-5044
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1438208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0003GSOtherBCBSTX GRP TPI NUMBER
1124098447OtherGRP NPI NUMBER
TX7431344OtherAETNA PIN
TX8B2072OtherBCBSTX IND PIN
TX080626701Medicaid
TX151675902Medicaid
TX202136OtherFIRSTHEALTH PIN
TX124179OtherSUPERIOR PIN
TX151675901Medicaid
TX163314102Medicaid
TX124179OtherSUPERIOR PIN