Provider Demographics
NPI:1801165873
Name:RAVELLA, SUPRIYA (MD)
Entity type:Individual
Prefix:DR
First Name:SUPRIYA
Middle Name:
Last Name:RAVELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 PUCHALA DR
Mailing Address - Street 2:
Mailing Address - City:PARLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08859-2198
Mailing Address - Country:US
Mailing Address - Phone:732-690-3298
Mailing Address - Fax:
Practice Address - Street 1:546 SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-2542
Practice Address - Country:US
Practice Address - Phone:732-381-3642
Practice Address - Fax:732-396-4463
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA09174800207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program