Provider Demographics
NPI:1649473539
Name:REVELO, DRAZEN (PT)
Entity type:Individual
Prefix:MR
First Name:DRAZEN
Middle Name:
Last Name:REVELO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 E PISTACHIO ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-7817
Mailing Address - Country:US
Mailing Address - Phone:516-849-6223
Mailing Address - Fax:
Practice Address - Street 1:531 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2315
Practice Address - Country:US
Practice Address - Phone:213-683-9390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist