Provider Demographics
NPI:1285355404
Name:REVELES, MELISSA (OD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:REVELES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 18TH AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-1796
Mailing Address - Country:US
Mailing Address - Phone:817-501-6562
Mailing Address - Fax:
Practice Address - Street 1:17550 W BLUEMOUND RD STE D
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2928
Practice Address - Country:US
Practice Address - Phone:262-784-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3808-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist