Provider Demographics
NPI:1356579304
Name:REVELO, OLVIA (MD)
Entity type:Individual
Prefix:
First Name:OLVIA
Middle Name:
Last Name:REVELO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18220 STATE HIGHWAY 249
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4347
Mailing Address - Country:US
Mailing Address - Phone:281-737-0570
Mailing Address - Fax:281-807-6024
Practice Address - Street 1:18220 STATE HIGHWAY 249
Practice Address - Street 2:SUITE 400
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4347
Practice Address - Country:US
Practice Address - Phone:281-737-0570
Practice Address - Fax:281-807-6024
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK34152207Q00000X
LA311025207Q00000X
ARE-11861207Q00000X
MO2019000473207Q00000X
MA277453207Q00000X
TXP1486207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01467090OtherRR MEDICARE
TX8FT326OtherBLUE CROSS BLUE SHIELD
TX8EL997OtherBLUE CROSS BLUE SHIELD
TX295420801Medicaid
TX295420803Medicaid
TXTXB151364Medicare PIN
TX8FT326OtherBLUE CROSS BLUE SHIELD
TX302042ZSWDMedicare PIN