Provider Demographics
NPI:1215918990
Name:TREVINO, DAVID R (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:TREVINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W LANCASTER AVE
Mailing Address - Street 2:MOB II SUITE 121
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1763
Mailing Address - Country:US
Mailing Address - Phone:610-647-8885
Mailing Address - Fax:610-640-3832
Practice Address - Street 1:255 W LANCASTER AVE
Practice Address - Street 2:MOB II SUITE 121
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1763
Practice Address - Country:US
Practice Address - Phone:610-647-8885
Practice Address - Fax:610-640-3832
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025295E207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA110225028OtherRAILROAD MEDICARE
B34476Medicare UPIN
PA110225028OtherRAILROAD MEDICARE