Provider Demographics
NPI:1679964399
Name:TREVISANI CENTRE PA
Entity type:Organization
Organization Name:TREVISANI CENTRE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:TREVISANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-677-8999
Mailing Address - Street 1:413 LAKE HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5906
Mailing Address - Country:US
Mailing Address - Phone:407-677-8999
Mailing Address - Fax:
Practice Address - Street 1:413 LAKE HOWELL RD
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5906
Practice Address - Country:US
Practice Address - Phone:407-677-8999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL63930208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty