Healthcare Provider Details

I. General information

NPI: 1376535807
Provider Name (Legal Business Name): JOSEPH JAVIER BRAVO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 636324
CINCINNATI OH
45263-6324
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2000
  • Fax: 859-301-5690
Mailing address:
  • Phone: 859-334-5555
  • Fax: 859-334-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number18650
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number18650
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: