Healthcare Provider Details

I. General information

NPI: 1235463654
Provider Name (Legal Business Name): PATRICIA BRAVO M.D,P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 06/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 79TH STREET CSWY SUITE #1400
NORTH BAY VILLAGE FL
33141-4188
US

IV. Provider business mailing address

1440 79TH STREET CSWY SUITE #1400
NORTH BAY VILLAGE FL
33141-4188
US

V. Phone/Fax

Practice location:
  • Phone: 305-763-8573
  • Fax: 305-763-8574
Mailing address:
  • Phone: 305-763-8573
  • Fax: 305-763-8574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME 91464
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PATRICIA BRAVO
Title or Position: DIRECTOR
Credential: MD
Phone: 305-763-8573