Provider Demographics
NPI:1508002684
Name:RAVAL, JAY SUMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:SUMAN
Last Name:RAVAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 TINNIN RD NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-7107
Mailing Address - Country:US
Mailing Address - Phone:919-618-3621
Mailing Address - Fax:
Practice Address - Street 1:5801 TINNIN RD NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107
Practice Address - Country:US
Practice Address - Phone:919-618-3621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-19
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2018-0755207ZB0001X
PAMD438567207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD438567OtherCOMMONWEALTH OF PENNSYLVANIA UNRESTRICTED MEDICAL LICENSE