Provider Demographics
NPI:1255627477
Name:MANCHENO REVELO, ADRIAN ALEXANDER (MD)
Entity type:Individual
Prefix:DR
First Name:ADRIAN
Middle Name:ALEXANDER
Last Name:MANCHENO REVELO
Suffix:
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 1:1105 CLARENDON ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-3511
Mailing Address - Country:US
Mailing Address - Phone:828-551-8654
Mailing Address - Fax:
Practice Address - Street 1:1214 VAUGHN RD
Practice Address - Street 2:1 ST FLOOR
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2863
Practice Address - Country:US
Practice Address - Phone:919-537-7473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172999207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine