Provider Demographics
NPI:1487861308
Name:REVELLE, BRYAN MITCHELL (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:MITCHELL
Last Name:REVELLE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1645
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78680-1645
Mailing Address - Country:US
Mailing Address - Phone:512-248-0912
Mailing Address - Fax:512-248-0941
Practice Address - Street 1:2840 COLLINGWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-5655
Practice Address - Country:US
Practice Address - Phone:512-248-0912
Practice Address - Fax:512-248-0941
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1695213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU92274Medicare UPIN