Healthcare Provider Details

I. General information

NPI: 1265455505
Provider Name (Legal Business Name): JESSE RAEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3883 AIRWAY DR
SANTA ROSA CA
95403-1670
US

IV. Provider business mailing address

4901 LANG AVE NE
ALBUQUERQUE NM
87109
US

V. Phone/Fax

Practice location:
  • Phone: 707-521-4480
  • Fax:
Mailing address:
  • Phone: 505-842-8171
  • Fax: 505-246-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number86312
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG89384
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number86312
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: