Provider Demographics
NPI:1528314275
Name:REVELLE, ANDREW JOEL (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JOEL
Last Name:REVELLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1500
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-302-2287
Practice Address - Fax:573-302-2241
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVED0312A207RB0002X
MO2015013067207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine