Healthcare Provider Details

I. General information

NPI: 1669536009
Provider Name (Legal Business Name): GARY LEWIS BRAVO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 CHANATE RD
SANTA ROSA CA
95404-1708
US

IV. Provider business mailing address

3322 CHANATE RD
SANTA ROSA CA
95404-1708
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-4997
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG53626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: