Provider Demographics
NPI:1841931045
Name:REVILLA ORELLANO, RADAMES (MD)
Entity type:Individual
Prefix:
First Name:RADAMES
Middle Name:
Last Name:REVILLA ORELLANO
Suffix:
Gender:
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:ALTOS DEL ESCORIAL 504. BLVD MEDIA LUNA APT. 402
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987
Mailing Address - Country:US
Mailing Address - Phone:787-613-7748
Mailing Address - Fax:
Practice Address - Street 1:PASEO DR. JOSE CELSO BARBOSA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:787-758-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17087207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program