Provider Demographics
NPI:1154588127
Name:REVAK, CAROL (NMD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:REVAK
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S TUDOR PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-4256
Mailing Address - Country:US
Mailing Address - Phone:520-401-7595
Mailing Address - Fax:
Practice Address - Street 1:640 S TUDOR PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-4256
Practice Address - Country:US
Practice Address - Phone:520-749-9655
Practice Address - Fax:520-239-8515
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ 97-0516171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ 97-05516OtherBUSINESS LICENSE