Healthcare Provider Details

I. General information

NPI: 1528405636
Provider Name (Legal Business Name): MICHELLE BRAVO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BRADHURST AVE STE 3100N
HAWTHORNE NY
10532-2140
US

IV. Provider business mailing address

100 WOODS RD
VALHALLA NY
10595-1530
US

V. Phone/Fax

Practice location:
  • Phone: 914-493-7000
  • Fax:
Mailing address:
  • Phone: 914-493-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberLP02787
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLP02787
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number310127
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: