Provider Demographics
NPI:1386810091
Name:REVENCO, DIANA (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:REVENCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 9TH AVE
Mailing Address - Street 2:MS:M4-PFS
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:6919 N DALE MABRY HWY STE 125
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-3972
Practice Address - Country:US
Practice Address - Phone:813-497-9661
Practice Address - Fax:813-615-8468
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH15634207UN0901X
WAMD60668587207RC0000X
FLME146373207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHP01138997OtherRR MEDICARE
NH3075998Medicaid
ME1386810091Medicaid
NH3075998Medicaid