Healthcare Provider Details

I. General information

NPI: 1508002684
Provider Name (Legal Business Name): JAY SUMAN RAVAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2008
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 TINNIN RD NW
LOS RANCHOS NM
87107
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 919-618-3621
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License NumberMD2018-0755
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: