Basic Information
Provider Information | |||||||||
NPI: | 1629561170 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AREVALO | ||||||||
FirstName: | JOHN BENJAMIN | ||||||||
MiddleName: | JESS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, MBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | AREVALO | ||||||||
OtherFirstName: | BEN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD, MBA | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 533 PARNASSUS AVE | ||||||||
Address2: |   | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941432208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4154764838 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 533 PARNASSUS AVE | ||||||||
Address2: |   | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941432208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4154764838 | ||||||||
FaxNumber: | 8887554574 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2018 | ||||||||
LastUpdateDate: | 09/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 125.072417 | IL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207PH0002X | A174705 | CA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Hospice and Palliative Medicine |
No ID Information.