Provider Demographics
NPI:1912963893
Name:RAVAN ANDREWS, JACQUELYN VALERIE (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:VALERIE
Last Name:RAVAN ANDREWS
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:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284
Mailing Address - Country:US
Mailing Address - Phone:214-645-0624
Mailing Address - Fax:214-645-0078
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390
Practice Address - Country:US
Practice Address - Phone:214-645-0624
Practice Address - Fax:214-645-0078
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK13412086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100666003Medicaid
E95493Medicare UPIN
TX8G0252Medicare ID - Type Unspecified