Provider Demographics
NPI:1851371058
Name:REVELL, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:REVELL
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:PO BOX 1680
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25717-1680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:308 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WV
Practice Address - Zip Code:25541-1508
Practice Address - Country:US
Practice Address - Phone:304-743-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10966207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00123438OtherRR MEDICARE
WV001709560OtherMT. STATE
WV000000178444OtherANTHEM
WV0049623000Medicaid
OH0796652Medicaid
WV000000178444OtherANTHEM
WV001709560OtherMT. STATE