Individual
ANTONIO G REVILLA JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1880 E COMMERCIAL BLVD, SUITE 3, FORT LAUDERDALE, FL 33308-3747
(954) 772-0949
(954) 772-0957
Mailing address
1880 E COMMERCIAL BLVD, SUITE 3, FORT LAUDERDALE, FL 33308-3747
(954) 772-0949
(954) 772-0957
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
ME21737
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
055667000
—
FL
Enumeration date
07/15/2006
Last updated
03/06/2013
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