Provider Demographics
NPI:1790393486
Name:SAFFO, REVARD JOSEPH
Entity Type:Individual
Prefix:
First Name:REVARD
Middle Name:JOSEPH
Last Name:SAFFO
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 1:29348 DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2891
Mailing Address - Country:US
Mailing Address - Phone:248-933-5288
Mailing Address - Fax:
Practice Address - Street 1:14825 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2642
Practice Address - Country:US
Practice Address - Phone:313-383-7071
Practice Address - Fax:313-383-7194
Is Sole Proprietor?:No
Enumeration Date:2020-07-19
Last Update Date:2020-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704335406363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily