Provider Demographics
NPI:1376724773
Name:RAVAL, DEENA G (DO)
Entity Type:Individual
Prefix:DR
First Name:DEENA
Middle Name:G
Last Name:RAVAL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:201 S WABENA AVE
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-8715
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:
Practice Address - Street 1:1345 EDWARDS ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1691
Practice Address - Country:US
Practice Address - Phone:815-942-9299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125051090207R00000X
IL036122342207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036122342Medicaid
IL036122342Medicaid