Provider Demographics
NPI:1194794032
Name:DUER, REVITAL (PT)
Entity type:Individual
Prefix:
First Name:REVITAL
Middle Name:
Last Name:DUER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3366 E THOUSAND OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-3443
Mailing Address - Country:US
Mailing Address - Phone:805-374-9900
Mailing Address - Fax:805-374-9910
Practice Address - Street 1:3366 E THOUSAND OAKS BLVD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-3443
Practice Address - Country:US
Practice Address - Phone:805-374-9900
Practice Address - Fax:805-374-9910
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30187225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT301870OtherBLUE SHIELD IDENTIFIER
CAZZZ082282OtherBLUE SHIELD GROUP IDENTIF
CAW17334Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
CAWPT30187AMedicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #