Provider Demographics
NPI:1477666279
Name:REVILLA, RODOLFO MANUEL
Entity Type:Individual
Prefix:
First Name:RODOLFO
Middle Name:MANUEL
Last Name:REVILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:#309
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902
Mailing Address - Country:US
Mailing Address - Phone:915-532-9100
Mailing Address - Fax:915-532-9652
Practice Address - Street 1:1600 MEDICAL CENTER
Practice Address - Street 2:SUITE 309
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902
Practice Address - Country:US
Practice Address - Phone:915-532-9100
Practice Address - Fax:915-532-9652
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2462207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F36830Medicare UPIN
TXN80VMedicare ID - Type Unspecified