Provider Demographics
NPI:1023306859
Name:REVAK, THOMAS JOHN (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:REVAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 SOUTH SPRING AVENUE
Mailing Address - Street 2:ORTHOPAEDIC SURGERY, SLUCARE ADMINISTRATIVE PAVILLION F
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:314-977-5350
Mailing Address - Fax:
Practice Address - Street 1:1008 SOUTH SPRING AVENUE
Practice Address - Street 2:ORTHOPAEDIC SURGERY, SLUCARE ADMINISTRATIVE PAVILLION F
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:314-977-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014391207X00000X
MO2015015073207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOT014391OtherTRAINING LICENSES