Provider Demographics
NPI:1720329378
Name:REVOLLO, MARTHA LORENA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:LORENA
Last Name:REVOLLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9980 CENTRAL PARK BLVD N
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-1762
Mailing Address - Country:US
Mailing Address - Phone:561-558-1212
Mailing Address - Fax:
Practice Address - Street 1:9980 CENTRAL PARK BLVD N
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-1762
Practice Address - Country:US
Practice Address - Phone:561-558-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1414932080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology