Provider Demographics
NPI:1417238015
Name:REVITALIZE LLC
Entity Type:Organization
Organization Name:REVITALIZE LLC
Other - Org Name:OPTIMAL HEALTH PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NORTON
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-330-9430
Mailing Address - Street 1:15235 SHADY GROVE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3234
Mailing Address - Country:US
Mailing Address - Phone:301-330-9430
Mailing Address - Fax:301-330-6515
Practice Address - Street 1:15235 SHADY GROVE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3234
Practice Address - Country:US
Practice Address - Phone:301-330-9430
Practice Address - Fax:301-330-6515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-09
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH67624207Q00000X
MDD0050126207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty