Provider Demographics
NPI:1467615658
Name:REVERE, DAVID JON (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JON
Last Name:REVERE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10421 68TH DR
Mailing Address - Street 2:APT. B47
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27005 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1402
Practice Address - Country:US
Practice Address - Phone:718-470-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240831207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease