Provider Demographics
NPI:1881333003
Name:REVELO, GABRIEL ALEXIS
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ALEXIS
Last Name:REVELO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 BENTGRASS DR
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-3948
Mailing Address - Country:US
Mailing Address - Phone:443-653-2725
Mailing Address - Fax:
Practice Address - Street 1:1605 ROLAND HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-1685
Practice Address - Country:US
Practice Address - Phone:443-653-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-04
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD292242081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine