Provider Demographics
NPI:1013934470
Name:REVILLA, ANTONIO G JR (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:G
Last Name:REVILLA
Suffix:JR
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 1:1880 E COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3747
Mailing Address - Country:US
Mailing Address - Phone:954-772-0949
Mailing Address - Fax:954-772-0957
Practice Address - Street 1:1880 E COMMERCIAL BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3747
Practice Address - Country:US
Practice Address - Phone:954-772-0949
Practice Address - Fax:954-772-0957
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME21737174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055667000Medicaid
FL93104Medicare ID - Type Unspecified
FL055667000Medicaid