Provider Demographics
NPI:1316957152
Name:TREVISANI, JON PAUL (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:PAUL
Last Name:TREVISANI
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 1:413 LAKE HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5906
Mailing Address - Country:US
Mailing Address - Phone:407-677-8999
Mailing Address - Fax:407-677-5490
Practice Address - Street 1:413 LAKE HOWELL RD
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5906
Practice Address - Country:US
Practice Address - Phone:407-677-8999
Practice Address - Fax:407-677-5490
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL63930208200000X
NY191685-1208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26736Medicare ID - Type Unspecified
FLG03850Medicare UPIN