Provider Demographics
NPI:1487676516
Name:REVAI, JUDY PARK (OD)
Entity type:Individual
Prefix:DR
First Name:JUDY
Middle Name:PARK
Last Name:REVAI
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 1:228 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-1244
Mailing Address - Country:US
Mailing Address - Phone:518-439-7012
Mailing Address - Fax:
Practice Address - Street 1:228 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1244
Practice Address - Country:US
Practice Address - Phone:518-439-7012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007950152W00000X
CA11201T152W00000X
PAOEG001245152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU84068Medicare UPIN