Provider Demographics
NPI:1679050579
Name:REVELO ESCOBAR, JORGE MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:MANUEL
Last Name:REVELO ESCOBAR
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 1:7901 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-2156
Mailing Address - Fax:
Practice Address - Street 1:7901 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-2156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY316622-01208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics