Provider Demographics
NPI:1184149551
Name:TREVISAN, DAVID (MSOP, CO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:TREVISAN
Suffix:
Gender:M
Credentials:MSOP, CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3517
Mailing Address - Country:US
Mailing Address - Phone:517-784-1142
Mailing Address - Fax:
Practice Address - Street 1:1407 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3517
Practice Address - Country:US
Practice Address - Phone:517-784-1142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI222Z00000XMedicaid