Healthcare Provider Details

I. General information

NPI: 1235427675
Provider Name (Legal Business Name): PRIYANKA RAVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 LANEY WALKER BLVD
AUGUSTA GA
30912-0002
US

IV. Provider business mailing address

1120 15TH STREET BAA 5407
AUGUSTA GA
30912-3001
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-6744
  • Fax:
Mailing address:
  • Phone: 706-721-2505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number78222
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2011012664
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: