Provider Demographics
NPI:1740240647
Name:REAVILL, OLGA E (MD)
Entity Type:Individual
Prefix:MS
First Name:OLGA
Middle Name:E
Last Name:REAVILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-7274
Mailing Address - Country:US
Mailing Address - Phone:337-255-4081
Mailing Address - Fax:
Practice Address - Street 1:731 HWY 35 UNIT G
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-4765
Practice Address - Country:US
Practice Address - Phone:732-455-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMD.L07184R207P00000X, 207Q00000X
TXH6764207L00000X
NJ25MA10701700207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LADISP.200276OtherDISPENSING REGISTRATION
LA1388441Medicaid
LA1388441Medicaid
LA5CT47Medicare ID - Type UnspecifiedGROUP
LAB30702Medicare UPIN