Healthcare Provider Details

I. General information

NPI: 1962620294
Provider Name (Legal Business Name): IRACEMA AREVALO M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 S TAFT AVE
FREMONT OH
43420-3200
US

IV. Provider business mailing address

18 FOX RUN DR
FREMONT OH
43420-8562
US

V. Phone/Fax

Practice location:
  • Phone: 419-334-6679
  • Fax: 419-334-6690
Mailing address:
  • Phone: 567-201-2213
  • Fax: 419-334-8546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number35089621
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number35. 089621
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: