Active NPI
Antonio G Revilla Jr., MD
- Specialist
- Fort Lauderdale, FL
National Provider Identifier
1013934470
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Specialist
- License
- ME21737
- Practice address
- 1880 E Commercial Blvd
Suite 3
Fort Lauderdale, FL 33308-3747 - Phone
- (954) 772-0949
- Fax
- (954) 772-0957
- NPI assigned
- Jul 15, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist | 174400000X | ME21737 | FL | Primary |
Addresses
Primary practice location
1880 E Commercial Blvd
Suite 3
Fort Lauderdale, FL 33308-3747
Mailing address
1880 E Commercial Blvd
Suite 3
Fort Lauderdale, FL 33308-3747
Phone (954) 772-0949
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 055667000 | Medicaid | FL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 21737 | FL | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1152921600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1362528000000",
"number": "1013934470",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1880 E COMMERCIAL BLVD",
"address_2": "SUITE 3",
"city": "FORT LAUDERDALE",
"state": "FL",
"postal_code": "333083747",
"telephone_number": "954-772-0949",
"fax_number": "954-772-0957"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1880 E COMMERCIAL BLVD",
"address_2": "SUITE 3",
"city": "FORT LAUDERDALE",
"state": "FL",
"postal_code": "333083747",
"telephone_number": "954-772-0949",
"fax_number": "954-772-0957"
}
],
"practiceLocations": [],
"basic": {
"last_name": "REVILLA",
"first_name": "ANTONIO",
"middle_name": "G",
"name_suffix": "Jr.",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-07-15",
"last_updated": "2013-03-06",
"status": "A"
},
"taxonomies": [
{
"code": "174400000X",
"taxonomy_group": "",
"desc": "Specialist",
"state": "FL",
"license": "ME21737",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "055667000",
"state": "FL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Lauderdale, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 6, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.