Provider Demographics
NPI:1871751677
Name:BREVETTA, ROBERT ALEXANDER (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALEXANDER
Last Name:BREVETTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:727 SE MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3248
Practice Address - Country:US
Practice Address - Phone:864-454-6700
Practice Address - Fax:864-454-6705
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36753207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC367533Medicaid
SC367533Medicaid