Provider Demographics
NPI:1104066174
Name:RODOLFO M. REVILLA, MDPA
Entity type:Organization
Organization Name:RODOLFO M. REVILLA, MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:REVILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-532-9100
Mailing Address - Street 1:1600 MEDICAL CENTER DR STE 309
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-5008
Mailing Address - Country:US
Mailing Address - Phone:915-532-9100
Mailing Address - Fax:915-532-9652
Practice Address - Street 1:1600 MEDICAL CENTER DR STE 309
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5008
Practice Address - Country:US
Practice Address - Phone:915-532-9100
Practice Address - Fax:915-532-9652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-03
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160023417OtherRAIL ROAD PTAN #
TX203168401Medicaid
TXF36830OtherUPIN
TX203168401Medicaid