Healthcare Provider Details

I. General information

NPI: 1396026167
Provider Name (Legal Business Name): BRAULIO MARIANO MEJIA M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 N OLIVE AVE
WEST PALM BEACH FL
33401-3511
US

IV. Provider business mailing address

MQ10 PLAZA 37 URB. MONTE CLARO
BAYAMON PR
00961-3577
US

V. Phone/Fax

Practice location:
  • Phone: 561-833-7553
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberME129359
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number28999-R
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2018001274
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: