Provider Demographics
NPI:1568450575
Name:REVELLI, ANTHONY J (OD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:REVELLI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1773 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2105
Mailing Address - Country:US
Mailing Address - Phone:510-832-5625
Mailing Address - Fax:510-832-0614
Practice Address - Street 1:1773 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2105
Practice Address - Country:US
Practice Address - Phone:510-832-5625
Practice Address - Fax:510-832-0614
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5452T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0054520Medicare ID - Type UnspecifiedOFFICE SERVICES
CA0725410001Medicare ID - Type UnspecifiedVISION MATERIALS