1144367830 NPI number — DR. EDWARD JOSEPH REVELLI O.D.

Table of content: DR. EDWARD JOSEPH REVELLI O.D. (NPI 1144367830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144367830 NPI number — DR. EDWARD JOSEPH REVELLI O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REVELLI
Provider First Name:
EDWARD
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144367830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
UNIVERSITY OF CALIFORNIA 230 MINOR HALL
Provider Second Line Business Mailing Address:
SCHOOL OF OPTOMETRY
Provider Business Mailing Address City Name:
BERKELEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94720-2020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-642-0945
Provider Business Mailing Address Fax Number:
510-642-2893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
UNIVERSITY OF CALIFORNIA 230 MINOR HALL
Provider Second Line Business Practice Location Address:
SCHOOL OF OPTOMETRY
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94720-2020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-642-0945
Provider Business Practice Location Address Fax Number:
510-642-2893
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  6239 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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