Provider Demographics
NPI:1215908918
Name:SMITH, REVONNA JOY (DO)
Entity type:Individual
Prefix:DR
First Name:REVONNA
Middle Name:JOY
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:REVONNA
Other - Middle Name:J
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:104 PAWLEYS PLANTATION COURT
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45385
Mailing Address - Country:US
Mailing Address - Phone:937-374-3625
Mailing Address - Fax:
Practice Address - Street 1:3180 KETTERING BLVD.1141 N MONROE DRIVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439-1924
Practice Address - Country:US
Practice Address - Phone:937-297-6072
Practice Address - Fax:937-293-0969
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004618207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology