Provider Demographics
NPI:1013997360
Name:REVANA, MADAIAH (MD PA)
Entity Type:Individual
Prefix:
First Name:MADAIAH
Middle Name:
Last Name:REVANA
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18955 N MEMORIAL DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338-4264
Mailing Address - Country:US
Mailing Address - Phone:281-446-4638
Mailing Address - Fax:281-446-5386
Practice Address - Street 1:9950 MEMORIAL BLVD
Practice Address - Street 2:STE 201
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338
Practice Address - Country:US
Practice Address - Phone:281-446-4638
Practice Address - Fax:281-446-5386
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7719207UN0902X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX390396OtherWELLCARE
742018542OtherTAX ID
TX137528912Medicaid
82G136OtherBCBS
TX10016000OtherAMERIGROUP
TX137528912Medicaid