Provider Demographics
NPI:1194882571
Name:REVAN, VIDYASHANKAR B (MD)
Entity type:Individual
Prefix:
First Name:VIDYASHANKAR
Middle Name:B
Last Name:REVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VIDYASHANKAR
Other - Middle Name:B
Other - Last Name:REVANNASIDDAPPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9800 SHELBYVILLE RD STE 220
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2992
Mailing Address - Country:US
Mailing Address - Phone:502-429-8585
Mailing Address - Fax:502-753-0889
Practice Address - Street 1:110 FAIRWAY DR
Practice Address - Street 2:SUITE # 2
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-8756
Practice Address - Country:US
Practice Address - Phone:937-655-9179
Practice Address - Fax:937-655-9139
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080833207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2321660Medicaid
P00218102OtherRAIL ROAD MEDICARE
237121OtherBLUE CROSS BLUE SHIELD ID
H60978Medicare UPIN
OH2321660Medicaid