Individual
FREDY JESUS REVILLA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
200 PATEWOOD DR STE B350, GREENVILLE, SC 29615-6337
(864) 454-4500
(864) 454-4505
Mailing address
300 E MCBEE AVE FL 4, GREENVILLE, SC 29601-2842
(864) 522-8603
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
35083417
OH
2084N0400X
Neurology Physician
Primary
37641
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2463614
—
OH
05
—
376417
—
SC
01
—
P00113175
MEDICARE RAILROAD
OH
Enumeration date
06/23/2006
Last updated
06/29/2021
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