Provider Demographics
NPI:1306834981
Name:REVAK, ELSON L (DO)
Entity Type:Individual
Prefix:DR
First Name:ELSON
Middle Name:L
Last Name:REVAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3390 N CAMPBELL AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2380
Mailing Address - Country:US
Mailing Address - Phone:520-795-7650
Mailing Address - Fax:520-325-1622
Practice Address - Street 1:3390 N CAMPBELL AVE
Practice Address - Street 2:STE 110
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2380
Practice Address - Country:US
Practice Address - Phone:520-795-7650
Practice Address - Fax:520-325-1622
Is Sole Proprietor?:No
Enumeration Date:2005-10-08
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4272207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ105134Medicare ID - Type Unspecified
AZI39960Medicare UPIN