Healthcare Provider Details

I. General information

NPI: 1093797854
Provider Name (Legal Business Name): TERESA B BRAVO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904B CYPRESS PKWY
KISSIMMEE FL
34759-3456
US

IV. Provider business mailing address

904B CYPRESS PKWY
KISSIMMEE FL
34759-3456
US

V. Phone/Fax

Practice location:
  • Phone: 407-483-1400
  • Fax: 407-483-1405
Mailing address:
  • Phone: 786-697-3549
  • Fax: 865-381-1572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number043928
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME124549
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: