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NPI Code Detail

MEDICARE: MARK GLENN DRAVILLAS

MEDICARE: MARK GLENN DRAVILLAS
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
1390200000XStudent in an Organized Health Care Education/Training ProgramOH

General Provider Information

NPI Number : 1306770292
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARK GLENN DRAVILLAS
Provider Business Mailing Address
First Line : 1577 NEIL AVE
Second Line :
City : COLUMBUS
State : OH
Zip : 43210-1216
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1577 NEIL AVE
Second Line :
City : COLUMBUS
State : OH
Zip : 43210-1216
Country : US
Telephone Number : 614-292-4041
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/09/2026
Last Update Date : 06/09/2026

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