1669119525 NPI number — MS. GABRIELA DEL CARMEN SANTOS REVILLA M.D.

Table of content: MS. GABRIELA DEL CARMEN SANTOS REVILLA M.D. (NPI 1669119525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669119525 NPI number — MS. GABRIELA DEL CARMEN SANTOS REVILLA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANTOS REVILLA
Provider First Name:
GABRIELA
Provider Middle Name:
DEL CARMEN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1669119525
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
01/04/2023
NPI Reactivation Date:
03/23/2023

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2201 HEMPSTEAD TURNPIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST MEADOW
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-572-6637
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2201 HEMPSTEAD TURNPIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST MEADOW
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-572-6637
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2022

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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