Provider Demographics
NPI:1952738627
Name:REVELO SARAVIA, CARLOS A (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:REVELO SARAVIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 N LOVINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-9139
Mailing Address - Country:US
Mailing Address - Phone:575-392-1973
Mailing Address - Fax:
Practice Address - Street 1:121 EL PASO RD
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6033
Practice Address - Country:US
Practice Address - Phone:575-630-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMMD2015-0124207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM426536YKTNMedicare PIN