Healthcare Provider Details

I. General information

NPI: 1184868929
Provider Name (Legal Business Name): DAVID N. REAVIS MD, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 11/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 WAVERLY AVE
PATCHOGUE NY
11772-1523
US

IV. Provider business mailing address

603 WAVERLY AVE
PATCHOGUE NY
11772-1523
US

V. Phone/Fax

Practice location:
  • Phone: 631-482-3116
  • Fax: 631-466-3531
Mailing address:
  • Phone: 631-482-3116
  • Fax: 631-466-3531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number210125-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. DAVID NEAL REAVIS
Title or Position: PRESIDENT
Credential: MD
Phone: 631-584-0010