Healthcare Provider Details

I. General information

NPI: 1639879836
Provider Name (Legal Business Name): VICTORIA SEFCSIK-REVELLE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA SEFCSIK DO

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 POLIFKA DR
SHAW AFB SC
29152-5100
US

IV. Provider business mailing address

420 POLIFKA DR
SHAW AFB SC
29152-5100
US

V. Phone/Fax

Practice location:
  • Phone: 803-985-6587
  • Fax: 803-895-6063
Mailing address:
  • Phone: 702-653-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2024035186
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: