Provider Demographics
NPI:1770726390
Name:JOSEPH, REVERSA R (MD)
Entity type:Individual
Prefix:
First Name:REVERSA
Middle Name:R
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REVERSA
Other - Middle Name:R
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:420 N JAMES RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-1834
Mailing Address - Country:US
Mailing Address - Phone:614-257-5208
Mailing Address - Fax:
Practice Address - Street 1:420 N JAMES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219
Practice Address - Country:US
Practice Address - Phone:614-257-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH351289552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0185738Medicaid
OHH508751Medicare PIN
OHH508750Medicare PIN