Healthcare Provider Details

I. General information

NPI: 1194882571
Provider Name (Legal Business Name): VIDYASHANKAR B REVAN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: VIDYASHANKAR B REVANNASIDDAPPA M.D.

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 FAIRWAY DR SUITE # 2
WILMINGTON OH
45177-8756
US

IV. Provider business mailing address

9800 SHELBYVILLE RD STE 220
LOUISVILLE KY
40223-2992
US

V. Phone/Fax

Practice location:
  • Phone: 937-655-9179
  • Fax: 937-655-9139
Mailing address:
  • Phone: 502-429-8585
  • Fax: 502-753-0889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number35080833
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: