Healthcare Provider Details

I. General information

NPI: 1629301817
Provider Name (Legal Business Name): JUAN RAVELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2009
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 ESSEX ST STE 302
HACKENSACK NJ
07601-8566
US

IV. Provider business mailing address

10 CENTER DRIVE BG 10 RM 12C103
BETHESDA MD
20814
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2065
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberD73924
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number25MA10848800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: