Healthcare Provider Details

I. General information

NPI: 1144499336
Provider Name (Legal Business Name): JOHN BRAVO DACANAY MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E MAIN ST SUITE A
PAYSON AZ
85541-5618
US

IV. Provider business mailing address

120 E MAIN ST SUITE A
PAYSON AZ
85541-5618
US

V. Phone/Fax

Practice location:
  • Phone: 928-474-9744
  • Fax:
Mailing address:
  • Phone: 928-474-9744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number37784
License Number StateAZ

VIII. Authorized Official

Name: JOHN B DACANAY
Title or Position: OWNER
Credential:
Phone: 928-474-9744