MEDICARE: DAVID TREVISAN MSOP, CO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Z00000X	Orthotist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184149551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID TREVISAN MSOP, CO

Provider Business Mailing Address
First Line	:	1407 E MICHIGAN AVE
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202-3517
Country	:	US
Telephone Number	:	517-784-1142
Fax Number	:

Provider Business Practice Location Address
First Line	:	1407 E MICHIGAN AVE
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202-3517
Country	:	US
Telephone Number	:	517-784-1142
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2017
Last Update Date	:	07/21/2022

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