Provider Demographics
NPI:1790965176
Name:JAMES REVELAS, D.P.M.
Entity Type:Organization
Organization Name:JAMES REVELAS, D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:REVELAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:419-663-3338
Mailing Address - Street 1:64 EXECUTIVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857
Mailing Address - Country:US
Mailing Address - Phone:419-663-3338
Mailing Address - Fax:419-668-4731
Practice Address - Street 1:64 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-9568
Practice Address - Country:US
Practice Address - Phone:419-663-3338
Practice Address - Fax:419-668-4731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-2443R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1103120001Medicare NSC
OH9293931Medicare PIN