Provider Demographics
NPI:1023237484
Name:REVIS, DONALD RAY II (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:RAY
Last Name:REVIS
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:649 SW 8TH TER
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33315-1049
Mailing Address - Country:US
Mailing Address - Phone:954-760-4727
Mailing Address - Fax:
Practice Address - Street 1:2500 N FEDERAL HWY
Practice Address - Street 2:SUITE 301
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305-1618
Practice Address - Country:US
Practice Address - Phone:954-630-2009
Practice Address - Fax:954-630-2094
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00763222086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery