Healthcare Provider Details

I. General information

NPI: 1790965176
Provider Name (Legal Business Name): JAMES REVELAS, D.P.M.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 EXECUTIVE DR
NORWALK OH
44857-9568
US

IV. Provider business mailing address

64 EXECUTIVE DRIVE
NORWALK OH
44857
US

V. Phone/Fax

Practice location:
  • Phone: 419-663-3338
  • Fax: 419-668-4731
Mailing address:
  • Phone: 419-663-3338
  • Fax: 419-668-4731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36-00-2443R
License Number StateOH

VIII. Authorized Official

Name: DR. JAMES REVELAS
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 419-663-3338