Provider Demographics
NPI:1124251905
Name:REVENNAUGH, JAMES (OD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:REVENNAUGH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14073 SNOW MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-4466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:86 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-2818
Practice Address - Country:US
Practice Address - Phone:352-796-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4450152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1124251905Medicare PIN
FL1710179932Medicare NSC